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The Journal 

of the 

Michigan State Medical Society 

Published Under the Direction 
of the Council 

Publication Committee 

A. S. Brunk, M.D. (Chairman) 

F. T. Andrews, M.D. 

T. F. Heavenrich, M.D. 

Roy H. Holmes, M.D. 

J. Earl McIntyre, M.D. 


J. H. Dempster, M.D. 
Editor 


L. Fernald Foster, M.D., Secretary and Business Manager 
Wm. J. Burns, LL.B., Executive Secretary 


VOLUME 38 
1939 





THE JOURNAL 

OF THE 

Michigan State Medical Society 

ISSUED MONTHLY UNDER THE DIRECTION OF THE COUNCIL 

Vol. 38 JANUARY, 1939 No. 1 


THE DIAGNOSIS OF PYURIA IN CHILDHOOD AND ITS 
TREATMENT WITH MANDELIC ACID AND 
SULFANILAMIDE* 

HENRY F. HELMHOLZ, M.D. 

Section on Pediatrics, The Mayo Clinic 
ROCHESTER, MINNESOTA 


So much has been written about the frequency of pyuria in childhood 
that there has been a tendency to make the diagnosis every time a few 
pus cells are found in a specimen of urine which has been obtained in 
the usual manner. Pus cells in such a specimen may indicate an infec- 
tion of the bladder or upper urinary passages ; more frequently, however, 
they are merely evidence that there has been an admixture of pus from 
the vaginal secretion in the female or slight irritation under the prepuce 
of the male. 

The presence of pus cells in a single specimen of urine passed in the 
usual manner should never be relied on to make a diagnosis of inflam- 
mation of the upper urinary passages. In 
the female, a catheterized specimen of urine 
should be obtained from the bladder; this 
should be examined microscopically for pus, 
a centrifuged specimen should be stained by 
Gram’s method, and a culture should be 
made in order to ascertain the type of or- 
ganism which is causing the infection. In 
the male, the foreskin should be retracted, 
the meatus wiped with a little cotton (which 
has been moistened with sterile water) and, 
after the patient has passed a few cubic 
centimeters of urine to wash out the an- 
terior portion of the urethra, the specimen 
should be caught in a sterile container. In 
infants, and in the case of uncooperative 
older boys, a specimen may be obtained by 
means of a ureteral catheter. In this way 
the presence of infection can definitely be 
determined. Usually pus is found in the 

*Read before the meeting- of the Michigan State Medical 
Society, Detroit, Michigan, September 19-22, 1938. 


urine, Gram-negative bacilli in the smear 
and on cultures. If the culture and Gram 
stain prove to be negative for bacteria and 
if pus is present, it is likely that the patient 
is suffering from tuberculosis of the kidney. 
If the stain is positive and the plate culture 
negative after twenty-four hours, it is prob- 
able that the infection is due to an anaerobe 
or to some very slow-growing organism. 
Cultures are made with eosin-methylene 
blue agar, by means of which it is possible 
to differentiate between the most common 
of the Gram-negative bacilli found in the 
urine. Blood agar is used to differentiate 
the streptococci. 

Until recently, identification of the vari- 
ous so-called Gram-negative bacilli found 
in urinary infections was not carried out 
and, as long as the treatment in no way de- 
pended upon the particular type of organism 
that was present, it was not necessary to 



H. F. Helmholz 


January, 1939 


17 



DIAGNOSIS OF PYURIA— HELMHOLZ 


differentiate members of this group. Now 
that drugs are available which act different- 
ly on various organisms, however, and 
which act only when certain conditions are 
obtained in the urine, it becomes necessary 
to know which particular type or types of 
bacteria are causing the infection. An ex- 
ample of such a drug having a specific ac- 
tion is sulfanilamide. This drug does not 
affect Streptococcus fsecalis, however, and is 
thus useless in the treatment of infections 
caused by this organism. Another example 
is the almost insurmountable difficulty of 
acidfying the urine in infections with Pro- 
teus ammoniae, and still another is the great 
resistance of Pseudomonas infection to anti- 
septic therapy. 

A determination of the presence and type 
of infection must be followed by the de- 
termination of the status of renal function 
and the normality of urinary drainage. 
There are still too many children who have 
had their kidneys irreparably damaged by 
long-continued back pressure and infection 
before they were referred to a urologist 
for the relief of stasis. It is the duty of 
the physician treating infections of the uri- 
nary tract to include in his diagnostic pro- 
gram the determination of the renal func- 
tion and the absence of urinary stasis. Fa- 
cilities for the determination of the blood 
urea and for intravenous urograms are now 
within the reach of private practitioners al- 
most everywhere. 

It is very evident, therefore, that the 
diagnosis of an inflammatory lesion of the 
urinary passages should rest on more clini- 
cal data than the mere finding of some pus 
cells in the urine and, likewise, a cure on 
more evidence than a urine free of pus cells. 
Unfortunately, it is still very common to 
find the diagnosis based solely on the pres- 
ence of pus, and the cure on its disappear- 
ance from the urine. This all sounds very 
complicated, but it can be simplified in gen- 
eral practice. Bacteria alone, or with pus, 
found in a specimen properly obtained can 
be identified under the low power lens of a 
microscope, and culture for determination 
of the sterility of the urine can be very 
simply made with only a catheter and an 
agar tube. 

Having determined the existence of in- 
fection and its nature, and having ascer- 
tained that the function of the kidneys and 
urinary drainage are normal, how does one 


proceed with the treatment? It has been 
my experience that, in the hands of the man 
in general practice, the simplest mode of 
treatment is likely to give the best results. 
It is for this reason that I recommend sul- 
fanilamide. This drug is given in a stand- 
ard dose per pound of body weight and no 
attention needs to be paid to the reaction of 
the urine or to the concentration of the drug 
except when excessive amounts of fluid are 
prescribed. 

Sulfanilamide acts best in an alkaline 
urine and it usually produces an alkaline 
urine by the washing out of alkali. It is, 
therefore, well to give from 10 to 15 grains 
(0.65 to 1 gm.) of sodium bicarbonate three 
times a day with the sulfanilamide in order 
to prevent acidosis. The dose of sulfanila- 
mide which I have found to be sufficient in 
most cases is 10 grains (0.65 gm.) per 20 
pounds (9 kg.) of body weight; if neces- 
sary, the dose may be increased to 15 
grains (1 gm.) per 20 pounds of body 
weight, as recommended by Long in the 
treatment of streptococcus infection. For 
short periods the dose may be increased to 
20 grains (1.3 gm.) per 20 pounds of body 
weight. It is possible, further, to increase 
the urinary concentration without increasing 
the blood concentration by cutting down 
on the intake of fluids. 

Long has pointed out that cyanosis is 
of no significance as a toxic manifestation, 
but a rash, fever and rapid fall in the 
number of erythrocytes or leukocytes neces- 
sitates immediate withdrawal of the drug. 

For many years the administration of 
large amounts of fluids and alkalinization 
of the urine have been the standard treat- 
ment in acute cases of pyelitis, especially in 
infancy. In addition to this routine treat- 
ment, sulfanilamide can be given very ad- 
vantageously every four hours in the dosage 
just indicated. With the addition of sul- 
fanilamide to the scheme of treatment, the 
acute symptoms, high fever and restlessness 
may disappear at an earlier time than usual. 
Administration of the drug should be con- 
tinued in the same dosage until a culture 
of the urine no longer shows evidence of 
bacterial growth. The frequency with which 
bacteria return in cases in which administra- 
tion of the drug is discontinued immediately 
after the urine becomes sterile indicates 
the necessity for a longer period of anti- 
sepsis to cure the patient. The drug should 

Jour. M.S.M.S. 


18 


DIAGNOSIS OF PYURIA— HELMHOLZ 


be given for from four to six days after the 
urine has become sterile. If, at the end of 
a week, the urine is still found to be sterile, 
administration of the drug should be dis- 
continued and an interval of three or four 
days should be allowed to elapse. Another 
culture is then taken and if it, too, is sterile, 
one may be quite certain that the patient has 
been cured. If, on the other hand, the cul- 
ture of the urine again shows bacteria, then 
it must be assumed that bacterial growth in 
the urine was merely inhibited and that fur- 
ther treatment is necessary. Instead of 10 
grains, 15 grains of sulfanilamide per 20 
pounds body weight should next be tried 
and the same process repeated. It is advis- 
able in such cases to continue the same dos- 
age for eight to ten days after first obtain- 
ing a sterile urine. Four days after dis- 
continuation of the medication, the urine 
should again be checked by culture for steril- 
ity of the urine. The same procedure is 
carried out in cases of subacute and chronic 
infections, with the exception that no effort 
is made to force fluids. 

A rapid recovery from both acute and 
chronic infections is likely when the infect- 
ing organism is any one of the group of 
Gram-negative bacilli, Escherichia coli, 
Aerobacter aerogenes, Salmonella. Proteus 
vulgaris, or Proteus ammoniae. The same 
applies to staphylococcus infection of the 
lower portion of the urinary tract. Pseudom- 
onas infections are more difficult to cure. 
The excellent results obtained in treating in- 
fections with the bacillus, Proteus ammoniae 
(encrusted cystitis), should be emphasized 
because it, in particular, has been resistant 
to methenamine and mandelic acid as well 
as to therapy by means of the ketogenic diet. 
All three of these modes of treatment are 
dependent upon a strongly acid urine for 
their bactericidal action, and the highly alka- 
line nature of the urine in Proteus infections 
prevents this. 

When the function of the kidneys has 
been so reduced in chronic pyelonephritis 
that the A'alue for blood urea has risen above 
50 mg. per cent, the kidneys are usually 
unable to excrete urine of low pH. The 
same situation may arise when only one kid- 
ney is affected. The normal kidney is able 
to excrete urine of low pH with definite 
bactericidal power, whereas the affected kid- 
ney secretes a urine of higher pH without 
bactericidal power. It was very helpful to 
discover that sulfanilamide is secreted in 


bactericidal concentrations in the urine of 
patients who had values for blood urea vary- 
ing from 50 to 100 mg. per cent. In four 
of five such cases the urine was sterile, 
although only temporarily so. Such a re- 
sult I had never achieved with any other 
drug. The concentration of free sulfanila- 
mide in the urine never rose above 25 mg. 
per cent in these cases and yet a sterile urine 
was obtained in four of the five cases. 
Great care must be exercised in the treat- 
ment of this group of patients because the 
inability of the kidneys to secrete sulfanila- 
mide at the normal rate may result in the 
drug accumulating in the blood and produc- 
ing toxic symptoms. 

So far I have reported only the advan- 
tages of treatment by means of sulfanila- 
mide. Its one great drawback, however, is 
its ineffectiveness in treating infections 
caused by Streptococcus fsecalis. This strep- 
tococcus seems to grow luxuriantly in con- 
centrations of sulfanilamide which will rap- 
idly kill off bacilli of the Gram-negative 
group. 

Since I have used sulfanilamide it has 
become evident that Streptococcus fsecalis is 
a much more frequent invader of the uri- 
nary passages than I had formerly realized. 
I have found, on a number of occasions, 
that a patient with pyelitis, apparently a 
pure Escherichia coli infection, was rapidly 
rid of this organism by means of sulfanila- 
mide, only to find that the urine, on culture, 
then contained innumerable organisms of 
Streptococcus fsecalis. I found, in looking 
over old charts of patients infected with 
Escherichia coli who had been successfully 
treated with methenamine, the ketogenic 
diet, or mandelic acid, that it was not unu- 
sual, on culturing the urine, to find a few 
colonies of Streptococcus fsecalis on the agar 
plates after the Escherichia coli had com- 
pletely disappeared. The continuation of 
treatment usually resulted in the disappear- 
ance of these streptococci also. This would 
indicate that Streptococcus fsecalis does not 
grow in urine containing formaldehyde or 
organic acids as it does in urine containing 
sulfanilamide, and that it is more resistant 
to treatment than the colon bacillus but can 
eventually be killed off when treatment is 
persisted in. How frequently mixed infec- 
tions occur should become evident with the 
continued use of sulfanilamide. If there are 
many, the success of sulfanilamide therapy 


January, 1939 


19 


DIAGNOSIS OF PYURIA— HELMHOLZ 


will be decreased, and this will necessitate 
treatment by means of a combination of 
sulfanilamide and mandelic acid. 

Organic acid therapy was introduced in 
the form of the ketogenic diet. More suc- 
cessful than any previously used method 
of treatment, the difficulties of taking the 
diet were, nevertheless, such that, when 
Rosenheim showed that mandelic acid would 
act just as successfully as beta-oxybutyric 
acid in the cure of urinary infections, man- 
delic acid entirely replaced the diet. 

Mandelic acid acts bactericidally in a 
urine of a pH below 5.5 and at a concentra- 
tion greater than 0.5 per cent. Whenever 
these conditions can be attained, it is pos- 
sible to clear up infections caused by any 
of the usual organisms which are found in 
pyogenic infections of the urinary passages 
with the exception of the tubercle bacillus. 
The fact that these two conditions are neces- 
sary in order to obtain bactericidal action 
makes the treatment somewhat more difficult. 
However, in view of the fact that the acidi- 
fication of the urine and the concentration 
of mandelate in the urine is usually sufficient 
when ammonium mandelate or calcium man- 
delate is given in a dose of 1 gm. per day 
for every 100 c.c. of urinary output in twen- 
t 3 ^-four hours, it is usually possible to attain 
a good therapeutic result without further 
testing of the conditions of the urine. It is 
preferable to test the pH of the urine with 
nitrazine paper to make sure that it is below 
5.5. If necessary, ammonium nitrate (0.5 
gm. four times a day) may be given in addi- 
tion if the acidity is not great enough. The 
excretion of mandelate is almost entirely 
by the kidney, so that a dose of 1 gm. per 
100 c.c. of urinar)^ output practically assures 
a concentration more than 0.5 per cent. The 
usual adult dose of 45 grains (3 gm.) four 
times a day is given to children from twelve 
to fifteen years of age. Infants can take 
10 grains (0.65 gm.) four times a day and, 
depending on urinary output, a gradually in- 
creasing dose with age up to the adult dose. 

In the treatment of urinary infections by 
means of mandelic acid, the following pro- 
cedure is of advantage : On many occasions 
I have seen a sterile culture obtained from 
the urine twenty-four hours after starting 
treatment. It is advisable to continue treat- 
ment for three or four days after the urine 
has become sterile as tested by culture. Ad- 
ministration of the drug may then be dis- 
continued and, after another interval of 


three or four days, culture repeated; a ster- 
ile culture then indicates cure. The drug is 
not very palatable, and the ammonium salt 
cannot be easily disguised by any other fla- 
vor. The calcium salt is somewhat bitter 
but not particularly unpleasant. When the 
little patient will not take the drug, or can- 
not take it by mouth because of nausea and 
vomiting, it may be administered in supposi- 
tory form in exactly the same dose. 

Failures with mandelic acid therapy oc- 
cur in cases in which the function of the 
kidney is lowered and in which the neces- 
sary acidity of the urine cannot be reached. 
A recent patient, whose blood urea was 38 
mg. per cent, was cured of a colon bacillus 
infection by the use of sulfanilamide, only 
to have Streptococcus fsecalis appear, which 
could not be cleared up with mandelic acid 
because the pH of the urine could never be 
reduced to the bactericidal level. This may 
apply to one or both kidneys. In cases 
of infection with Proteus ammonise in which 
the alkaline reaction persists regardless of 
the giving of acid salts, the bactericidal 
range can never be reached. Fortunately, 
such cases are rare in infancy and child- 
hood. 

Treatment by means of sulfanilamide is, 
as has been indicated, easier to carry out 
than is treatment by the ketogenic diet, 
methenamine, or mandelic acid. It is suc- 
cessful in urine which is alkaline because 
of urea-splitting organisms, and it is suc- 
cessful in conditions in which the function 
of the kidney is reduced. Sulfanilamide, as 
has been said, is of no value in the treatment 
of infections with Streptococcus faecalis. 
Mandelic acid is of value in the treatment 
of all infections in which the urinary acidity 
can be reduced below 5.5 and the drug ex- 
creted in a concentration in 0.5 per cent. 

In conclusion, I wish to emphasize the 
duty of the physician in determining the 
absence of stasis in the urinary passages be- 
fore dismissing any patient he has been 
treating for infection of the urinary tract. 
Markedly lowered renal function is the one 
condition which prevents successful treat- 
ment, and only if infection and back pres- 
sure are recognized early will it be possible 
to prevent damage to the kidneys. An ex- 
cretory urogram and a culture of the urine 
will tell the story. Closer cooperation be- 
tween pediatricians and general practitioners 
and the urologist will save many deaths in 
later life from renal insufficiencv. 


20 


Jour. M.S.M.S. 


TREATMENT OF IMPOTENCE 


EDWIN W. HIRSCH, M.D* 

CHICAGO, ILLINOIS 


Impotence is the inability to perform the sexual act. It is a very common disturbance 
and one which often causes the urologist deep concern. The causes are roughly divisible 
into two groups: (1) Organic; (2) Psychogenic. This classification is not as valid as 
it may seem on the surface, for very often there is a blending of the two elements. A 
man suffering with impotence due to an organic lesion may appear to have a psychic 
disorder. Likewise — as is more often the case — a man with psychic impotence may sim- 
ulate true or organic impotencv. Also, psychic and organic factors may operate 
simultaneously. In men between the ages 
of twenty and forty, impotence, more gen- 
erally, is due to a disturbance in the psychic 
system than to an anatomic defect in the 
genitalia. 


By the use of the term impotence we do 
not merely imply that there exists a condi- 
tion of partial or incomplete erection. The 
inability to display or perceive the various 
manifestations which characterize physio- 
logical coitus, denotes a state of impotencv 
of greater or lesser degree. We recognize 
the stages of copulation as: (1) The stage 
of sexual excitement or the pre-copulatory 
phase; (2) The stage of increased glandular 
activity; (3) Erection; (4) Introduction 
of the phallus; (5) Frictional movement; 
(6) Existence of voluptuous or pleasurable 
sensation; (7) The orgasm; (8) Ejacula- 
tion; (9) Detumescence, or the return of 
the erect organ to a state of flaccidity. 

Erection is that physical state essential 
for the introduction of the phallus. It is 
essentially a process of hyperemia. The in- 
flux of arterial blood is augmented by 
heightened blood pressure and complete 
vaso-dilatation. Outflow of blood is pre- 
vented by a process of venus constriction. 
Physiologists and anatomists have given 
their best efforts to soEe the mystery of 
how blood is retained within the erectile 
bodies. Every sort of explanation has been 
offered. One theory that has gained con- 
siderable credence is that there exist special 
valves within the penile veins known as fun- 
nel valves which supposedly only function 
during sexual excitement and serve as com- 
plete barriers to the egress of blood. Time 
and again, attempts have been made to 
demonstrate special muscles within the veins 
which serve as vaso-constrictors. Anato- 
mists have also tried to prove that the uro- 


*Delivered before the Detroit branch of the American 
Urological Association, October 7, 1937, at Detroit, Michigan. 

January, 1939 


genital diaphragm is capable of blocking the 
outflow of blood. None of these explana- 
tions has been fortified by scientific proof. 

One of the first clues to the physiology 
of erection was furnished by the experiment 
popularly known to medical students of yes- 
teryear as the “wassersteite.” This consist- 
ed of placing a firm rubber band around 
the base of a cadaver penis and injecting 
water into the deep dorsal penile vein until 
the penis became firm and erect. While it 
is true that the penis of the cadaver may 
be made firm and erect in this manner, it 
does not follow that this is the process which 
is enacted in life. There is considerable evi- 
dence to show that it certainly is not the 
physiological modus operandi. In any num- 
ber of instances the deep and superficial 
dorsal veins have been ligated with the 
hope of producing erection by passive con- 
gestion. All such surgical efforts have end- 
ed in failure. 

It is my belief that blood is retained with- 
in the erectile bodies in sufficient volume to 
maintain organ turgidity, by the mechanical 
distension of the trabeculae against the ve- 
nous draining system. The arterial inflow 
is so voluminous and so sudden that the 
veins are temporarily choked off by the dis- 
tended blood spaces. Rigidity of the penis 
is due to the increased blood pressure with- 
in the penile arteries and the resultant dis- 
tension by the inflowing blood against the 
firm tunics and fascial coverings of the 
erectile bodies. Elevation of the penis is 
effected partly by the suspensory ligament 
of the penis and to .the anatomic fact that 
the dorsal surface of the penis is shorter 
than the ventral surface. The erector mus- 
cles aid in the process and also serve to sta- 
bilize the erection. 

A wide variety of stimuli may generate 
erection : 

21 


TREATMENT OF IMPOTENCE— HIRSCH 


1. Local stimulation of the sensitive 
nerve endings of the glans penis may induce 
erection. This may be a simple reflex proc- 
ess, independent of the higher cerebral cen- 
ters. 

2. Psychogenic erection resulting from 
phantasied images, or from previous im- 
pressions. 

3. Sensory impulses emanating from the 
organs of special sense are, undoubtedly, 
the usual mode of amusement. Stimulation 
from the libidinal zones serves to augment 
the intensity of the process. Emotional 
stimuli are conveyed to the sexual centers 
in the brain, from whence they pass through 
the extrapyramidal tracts to the centers reg- 
ulating the sympathetic system. Concomi- 
tantly, impulses are carried to the erector 
centers in the lumbar and sacral segments 
of the cord to the hypogastric plexus. From 
these sites impulses pass to the corpora cav- 
ernosa. 

4. Organ reflexes may generate erection. 
Over-distended seminal vesicles or a con- 
gested prostate, by pressure effects against 
their sympathetic innervation, may induce a 
hyperemic state of the erectile bodies. Irri- 
tation of the veru can readily induce an 
erection, a phenomenon often noted when 
silver nitrate is applied to the posterior 
urethra. 

5. Indirect pressure of the accessory sex- 
ual glands by a distended bladder is the ex- 
planation offered for the common morning 
erection which usually vanishes on emptying 
the urinary bladder.- 

6. Pathologic erection due to chronic de- 
generative processes. This type of erection 
is seen in cases of leukemia; severe forms 
of uremia; thrombus of the vessels draining 
the corpora cavernosa; tabes and neoplasm 
of the lower cord. 

7. Cerebral irritation induced by tumors 
of the pineal body is a condition rarely en- 
countered. 

8. Erection may be due to the irritant 
action of drugs such as follows the inges- 
tion of cantharides or yohimbin. 

The organic causes of impotency are 
classified in the following groups : ( 1 ) Con- 
genital deformities; (2) Endocrine disor- 
ders; (3) Diseases of the central nervous 
system; (4) Debilitating disorders ; (5) Lo- 
cal causes. 

For the sake of academic completeness, 
I shall list the main congenital disabilities, 

22 


though most of them are extremely rare. 
These defects are: Absence of penis; ab- 

normally small organ; absence of glans pe- 
nis; absence of erectile bodies; synechia of 
penis to scrotum ; an accessory urethra ; un- 
formed urethra ; epispadias ; hypospadias ; 
congenital fistula of the urethra; congenital 
stricture of the urethra; ectopia of the blad- 
der ; pseudohermaphrodism ; hermaphro- 
dism ; double penis ; bone in the penis ; short 
frsenum; urethral valves. 

Ever since the year 1889, when Brown- 
Sequard injected into himself a dilute and 
crude extract of testes, the subject of en- 
docrine influence in sexual potency has been 
gaining in importance. To recall the facts 
of this celebrated experiment, Brown- 
Sequard injected into himself 1 c.c. of tes- 
ticular extract daily for a period of two 
weeks. The improvement lasted for a 
month. He noticed that he felt less fatigue 
and in a certain sense experienced a feel- 
ing of rejuvenation. However, he admitted 
that suggestion probably played a consider- 
able part in the improvement. 

Decreased action of the thyroid, associ- 
ated with a lowered basal metabolism, may 
lower sexual vitality. Hyperpituitarism 
(acromegaly) may be responsible for loss 
of sexual power. More frequently, one 
sees cases of hypopituitarism (Frohlich’s 
syndrome), a condition characterized by ab- 
normal deposits of fat and an infantile-sized 
penis and testes. Impotency is also associ- 
ated with eunuchoidism and infantilism. 

Decreased sexual potency may be due to 
organic lesions of the central nervous sys- 
tem. Principally these affections are: in- 
jury to the brain and spinal cord; cerebral 
hemorrhage, thrombosis or embolism; cysts 
or tumors of the brain; lethargic encepha- 
litis ; meningitis ; multiple sclerosis ; mye- 
litis ; progressive paralysis ; premature 
arteriosclerosis; paralysis agitans; cerebro- 
spinal syphilis and tabes. In several of these 
afflictions priapism may precede impotency. 

Habitual use of certain drugs may lessen 
the libido. Morphine or one of its deriva- 
tives is a powerful depressant of the vita 
sexualis. Addiction to acetanilid or pheno- 
barbital may definitely curb the sexual ar- 
dor. Beer, wine or spiritus frumenti in mod- 
erate quantities act in most individuals as a 
tonic and serve to stabilize the sexual in- 
tegrity. I particuarly caution against the 
•use of most home brew concoctions. Dur- 

Tour. M.S.M.S. 


TREATMENT OF IMPOTENCE— HIRSCH 


ing the period of prohibition, I saw several 
cases of genital disorder which were trace- 
able to the poisonous action of improperly 
made alcoholic beverages. 

The local causes of impotency are most 
familiar to urologists and are the ones 
which are most amenable to treatment. 
These are: congenital phimosis; short frae- 
num; pin-point meatus; prostatitis; seminal 
vesiculitis; verumontanitis ; benign tumors 
of the veru; stricture of the anterior or 
posterior urethra; pathologic growths on 
the glans penis ; bladder, prostatic, and 
urethral stone. Among the more severe 
local causes of impotency there are: indu- 
ratio penis plastica; variocele, lrydrocele or 
hematocele which interefere with introduc- 
tion of the phallus; gangrene of the penis; 
traumatized perineum resulting from gun- 
shot or injury; fracture of the penis; the 
end-result of prostatectomy. 

Debilitating diseases such as pernicious 
anemia, severe secondary anemia; nephritis, 
arteriosclerosis, gout, diabetes mellitus and 
insipidus, cachexia, diseases due to vitamin 
deficiency, typhoid fever and influenza may 
undermine the erectile power. The toxins 
may exert their action on the endocrine or- 
gans or on the genital nerve plexuses. 

Coitus interruptus, commonly known as 
withdrawal, often does considerable harm 
to the sexual apparatus. This unphysio- 
logical method of prevent-ception induces 
prostatitis, seminal vesiculitis and verumon- 
tanitis, which in turn upset the normal 
neuro-muscular mechanism which operates 
in sustaining erection. If this practice is 
indulged over a period of many years, it is 
apt to lead to atony of the genital muscul- 
ture. Coitus prolongatus may have an in- 
jurious effect on the prostate. Coitus re- 
servatus — the act of performing coitus with- 
out ejaculating — may have a deleterious ef- 
fect. 

Correction of inadequate erection due to 
organic causes is obtained by medical and 
surgical measures. I will frankly state that 
I do not use nor have much confidence in 
the popular aphrodisiacs. The ineffective- 
ness of this group of drugs impressed itself 
on me many years ago, since which time I 
discontinued prescribing them. 

When definite signs exist that the thyroid 
gland is over- or under-functioning, I use 
the appropriate medication. Men with a 
very low basal metabolism often experience 

January, 1939 


a return of vitality when their metabolic 
rate is increased to a normal level. 

The injection of male sex hormones, has 
received wide application. Since Berthold 
in 1849 offered scientific proof that the tes- 
ticles control the size of cockerel combs, an 
overwhelming amount of research has been 
done along these lines. In experimental ani- 
mals, it has been shown that injection of 
androgen substances will increase skeletal 
growth, improve muscular tone, raise the 
metabolic rate, elevate the hemoglobin and 
oxidase content of the blood and tissues, 
and control the development of secondary 
sexual characteristics as well as the acces- 
sory reproductive organs. In humans, we 
do not know as yet just what usefulness 
these substances have in the treatment of 
impotence. In cases where there is definite 
evidence that the subject suffers from lack 
of male hormone, it is likely that therapeutic 
success may be achieved. Pituitary hormone 
is of definite value in impotency associated 
with the Frohlich syndrome. 

My most striking results in organic im- 
potency are obtained by employing ortho- 
dox urological measures in cases of prosta- 
titis, seminal vesiculitis and stricture of the 
urethra. Evacuation of stagnant secretion 
contained within the accessory sexual 
glands, stretching of scar tissue along the 
urethra or clearing up a cystitis due to 
post-gonorrhea infection or a non-specific 
infection, are measures which have brought 
spectacular results. 

Surgical procedures are definitely indi- 
cated in instances where there exists a pin- 
point meatus, a long adherent foreskin, 
valves in the urethra, hydrocele, hemato- 
cele or warty excrescences on the glans 
penis. Recently, I saw a case of impotency 
for which the patient had received con- 
siderable treatment. On examination, I 
found that he had a tiny meatus, and with- 
out any hesitation I injected some local anes- 
thetic and performed a meatotomy. Two 
days later, I examined the bladder and ure- 
thra with a cystourethroscope and found 
that he had a moderate-sized papillomatous 
growth on the edge of the trigone which 
floated back and forth within the internal 
urethral orifice. The subject of impotency 
immediately faded out of the picture and 
the neoplasm was attended to. What I am 
emphasizing is that no man should be 
treated for lessened sexual power unless 

23 


TREATMENT OF IMPOTENCE— HIRSCH 


he has had the benefit of a cystoscopic and 
urethroscopic examination. On one occa- 
sion, I found a bladder stone which was 
keeping up an inflamed posterior urethra 
by periodically rolling back and forth and 
making urination painful and coitus im- 
possible. 

Ligation of the superficial and deep dor- 
sal penile veins has no appreciable effect on 
the erectile power. A physician recently 
asked me to perform this operation on him- 
self. He felt certain that it would help him 
because, as he stated, “when I grasp the 
base of the penis and compress the vein, 
an erection ensues.” In compliance with his 
request, I ligated the superficial vein and 
as I prophesied, no visible effect ensued. 
The causative factors — stricture of the pos- 
terior urethra and an accompanying semin- 
al vesiculitis — are now being treated. 

Awakening of lost sexual power by the 
alleged rejuvenation operations of Steinach 
have been loudly advocated. Years ago, 
when surgeons treated prostatic enlarge- 
ment by vasoligation, no one made mention 
of any rejuvenating effects brought about 
by this procedure. It is only since prostatec- 
tomy was practiced that vasoligation seems 
to have benefited the fading power of aging 
men. In my opinion, tying off the vas 
brings about a feeling of rejuvenescence in 
only those cases where there exists a stag- 
nation within the seminal vesicles. Some 
cases of chronic vesiculitis are cured in this 
manner and the improvement is attributed 
to an increased activity of the interstitial 
cells of Leydig. 

Gland transplantation, which was inau- 
gurated by Lydston, agitated the public as 
well as the profession for several years, but 
produced no tangible results. This spectac- 
ular procedure has, I believe, seen its hey- 
day. 

Concerning the use of mechanical con- 
traptions to insure erection, I can only say 
that I have yet to hear a favorable report 
from one who has used such a contrivance. 

Recently, Lowsley introduced an oper- 
ation which consists in shortening the bul- 
bo — and ischio-cavernosi muscles. In a se- 
lected group, the early results were favor- 
able in a fair proportion of cases. Sufficient 
time has not yet elapsed to estimate the 
permanency of the improvement. 

24 


Psychic Impotency 

Sexual disorders which we now classify 
as psychic impotency were formerly re- 
garded as end-results of physical defects. 
That prevalent disorder, premature ejacula- 
tion, was treated on the basis that patholog- 
ical changes were responsible for this weak- 
ness. Since we have regarded ejaculatio 
pr?ecox from the psychopathologic view- 
point, much progress has been made in the 
amelioration of this embarrassing ailment. 
While some physical elements play a part 
in the so-called functional derangements, 
the main disturbance is within the psychic 
sphere. 

A comprehensive understanding concern- 
ing the genesis of sexual fear is essential to 
the proper management of psychic impo- 
teilcy. Practically all individuals are dom- 
inated to a greater or lesser extent by sex- 
ual fear during their developmental period. 
Dread of things sexual is dissipated gradual- 
ly on reaching maturity. Our civilization, 
by its rigid moral tenets, tends to inculcate 
an abnormal fear of the sexual component 
of life. Many children are frightened in 
their teens about sexual matters and these 
unpleasant memories lie dormant in their 
unconscious minds ready to dampen their 
sexual ardor when it blooms into fruition. 

Most youths on first experiencing noc- 
turnal emissions (pollutions) believe that 
this activity is due to impurity in thought. 
By the dissemination of sexual hygiene in- 
formation, we have tried to make known 
to the immature lad that there is nothing 
sinful in this natural process, which is mere- 
ly an indication that sexual maturity has 
begun. 

Our energies in this direction have been 
thwarted by the vast amount of literature 
which somehow or another finds its way 
to those who are perplexed by sexual prob- 
lems. Nor has all this literature emanated 
from quack sources. Practically every home 
library has its antiquated home medical ad- 
viser, which usually contains a chapter on 
the evils to which the flesh is heir. These 
accounts are quite harrowing, particularlv 
those which stress the penalty for indul- 
gence in masturbation. Many other sources 
of scare literature exist, all of which tend 
to depress the lad who needs help. 

A second cause of sexual fear is due to 
the GEdipus-complex, a condition developed 
by love rivalry in the home. The condi- 

Jour. M.S.M.S. 


TREATMENT OF IMPOTENCE— HIRSCH 


tion implies a too firm attachment of a 
son to his mother, so that the mature male 
has a difficult time diverting his attention to 
a feminine sexual object other than his 
mother. 

Castration complex, or the fear of losing 
one’s sexuality by sexual indulgence, is an 
unconscious psychic factor that operates 
to ingrain fear. Often, little boys are told 
that their sexual organ will wither or drop 
off if they touch the penis for improper 
purposes. 

Frustration of normal sex activity often 
results from false education and teaching 
that normal sexual activity is bestial. Those 
who have been overly impressed with this 
thought that the sexual function is degrad- 
ing have a difficult time in properly assert- 
ing their male characteristic at the proper 
time. 

Recognition of psychic impotency is 
usually not an easy matter. The subject 
may complain of vague pains in the penis, 
urethra, prostate, bladder, perineum or scro- 
tum. He may think that his organ is too 
large or too small; that the veins on or 
within the scrotum are too large; that an 
unusually strong odor emanates from his 
genitalia; or that a small quantity of mu- 
coid discharge from his meatus is the un- 
derlying cause of his sexual weakness. 
When the urologist’s attention is directed 
toward the genitalia, the recognition of 
sexual neurosis is relatively simple. 

In this short paper, I can merely hint at 
some of the other manifestations of psy- 
chical impotence. The symptoms are out of 
all proportion to the supposed causative fac- 
tor. Intense emotional upset is associated 
with the symptom-complex which is pre- 
sented. Vague neurotic pains are com- 
plained of. These are of shifting character. 
The subject shows indications of a marked 
feeling of inferiority. 

The physiology of the sexual neuroses 
is difficult to comprehend because it is so 
intimately related to the complicated sym- 
pathetic nervous system, the workings of 
which are just becoming intelligible to us. 
One might compare the state of sexual fear 
to that of stage fright. The speaker who 
is dominated by fear is embarrassed and 
is unable to use his organs as he normallv 
would. He perspires and loses all control. 
Merely standing up before an audience in- 
duces a state of physical instability. The 

January, 1939 


heart beats rapidly and self-possession is 
lost. Mosso, the Italian physiologist, and 
Crile, the surgeon physiologist, have em- 
phasized the relation of fear to organ de- 
rangement. Sexual fright can deflect the 
course of blood just as ordinary fright, 
which explains why those individuals who 
are unduly sensitive to emotional disturb- 
ances may lose their potency at the most 
inopportune moment. v 

The various psychological schools pre- 
sent interesting theories concerning the 
causative factors which lay the foundation 
for the development of psychic impotence. 
Freud considers the incest barrier as the 
psychic deterrent to normal expression in 
ejaculatio prsecox. Abraham believes that 
the precipitate emission of semen is the 
male’s mode of expressing disgust. Stekel 
regards this form of sexual weakness as an 
indication that the sexual inhibiting forces 
are stronger than the aggressive urge. The 
school of individual psychology states that 
sexual incompetency is the end-product of 
guilt feelings. My view is that it results 
from various types of fear which in turn 
induce involuntary contractions of the ejac- 
ulatory musclature. 

Frigidity can induce a state of impotence. 
The female may display an infantile atti- 
tude toward sex by such signs as vagin- 
ismus, genital hyperesthesia, hypersenitiv- 
ity or apparent indifference. All these con- 
ditions act as barriers to coitus. It may be 
caused by psychic trauma, an asocial atti- 
tude, or be a symptom of anxiety or a dis- 
like of copulation on moral or esthetic 
grounds. Without the display of impulsive- 
ness on the part of the female, there will 
be little reciprocal stimulation in the male. 

One of the reasons for the slow permea- 
tion of sexual psychology into the several 
regular departments of medicine, and urol- 
ogy in particular, is due to the dense screen 
of almost incomprehensible terminology 
which the psychologists use to define the 
sexual activity of man. To Adler we owe 
a debt for the simplification of complex and 
involved theories and to the psychobiolo- 
gists for their commonsense, everyday Eng- 
lish which they employ in defining abnorma 1 
states of being. Quibbling among the va- 
rious schools of psychology has tended to 
create a language which even adherents 
have difficulty in understanding. The term 
“libido” means one thing to one group and 


25 


TREATMENT OF IMPOTENCE— HIRSCH 


something else to another. Everything that 
transpires in the psychic world can be made 
intelligible to the practitioner with the av- 
erage I. Q. 

To uncover the etiological factors of a 
sex neurosis or a case of impotence, we 
first must obtain a good history. The mode 
of history taking is entirely different from 
that employed in a urological examination. 
Urologists, after a quick survey of the 
early diseases of childhood and the like, 
proceed to inquire into the localization of 
pain, urinary frequency, venereal history 
and the like. A form history is of no value 
in cases of impotence. Every phase of the 
individual’s life is considered. One should 
merely request the patient to talk about 
himself and at first the physician’s task is 
merely to listen. At the same time he must 
keep his ears open for points which appear 
to have a bearing on the development of 
the malady. If the patient is permitted to 
talk himself out, so to speak, he will ul- 
timately uncover sources of repressed ma- 
terial. During the first few sessions, the 
patient will present a plausible tale, and will 
make every effort to show his weaknesses in 
their best light. As the resistance of the 
patient wears away, he will become more 
confidential and will unearth his inner se- 
crets. A seemingly true initial confession 
may merely be the revelation of the upper 
strata of a troubled conscience. 

When the confidence of the diffident male 
has been completely won, the physician be- 
gins to interject queries which will open up 
new vistas of thought. At length a pro- 
spectus of the patient’s social and sexual 
life will have been unfolded. 

This unburdening process has a marked 
beneficial effect. Our next procedure is to 
discuss frankly the pet worries of the pa- 
tient so as to wash away the fears which 
haA^e beset him and have served to deflect 
his amatory assertiveness. Masturbation 
is but one of a long list of so-called sins 


Avhich engender a guilty conscience. One 
cannot dismiss the masturbation bogey by 
merely brushing the matter lightly aside. 
By sound logic, we must show the patient 
that the evils which he attributes to evil 
indulgence have not injured his sexual con- 
stitution. It is the fear of consequences at- 
tendent upon self-gratification Avhich causes 
so much harm. 

The ignorance of the average man in 
sexual matters is appalling. No one knows 
this better than the urologist. We must 
give them knowledge in a deft and inof- 
fensive manner. These patients are ex- 
tremely sensitive about their disability and 
must not be offended. Once the trick is 
learned of coaxing the patient to repose 
the utmost confidence in his physician, the 
most involved cases can be unraveled and 
cure is obtainable. 

In many instances, we must alter the pat- 
tern of the patient’s life. This is accom- 
plished by the employment of psychobiolog- 
ical principles. The designation “psycho- 
biology” pertains to the utilization of any 
aid which the several branches of medicine 
may offer, as well as that knowledge which 
is obtainable from the sciences or arts. 
There are no rigid rules which must be ad- 
hered to. The scope is broad and elastic. 
By the use of suitable measures, an asocial 
man may evolve into a social person and 
thus an asexual male can be converted into 
a sexual being. 

An air of hopelessness em r elops prac- 
tically all patients with psychic impotency. 
Physicians unfamiliar with the sordid view- 
point of the impotent will be overwhelmed, 
at first, Avith the patients’ depressive attitude 
and tone of despair. To listen to their tales 
is at times wearying, and I can assure you 
that the management of a single case of im- 
potency may entail more grief than several 
major urological operations. If, in the end, 
Ave manage to save a man’s life and his re- 
spect, it Avill be time well spent. 


26 


Jour. M.S.M.S. 


THE TREATMENT OF COMPOUND INJURIES WITH PARTICULAR 
REFERENCE TO THE HAND* 

SUMNER L. KOCH, M.D. 

CHICAGO, ILLINOIS 

Rather than read a formal paper and without wishing to make dogmatic and absolute 
statements I would like to discuss with you in a very informal way the broad problem 
of treatment of injuries, and in a little more detail the treatment of injuries of the hand. 
Needless to say, the surgical principles involved are identical, whether the injury involves 
the hand or some other part of the body. 

A word should be said at the outset concerning first aid. Much commendable and 
worthwhile effort has been exerted to inform the layman concerning the problems of 


medicine and surgery, but the advice given 
is sometimes confusing and based on illogi- 
cal premises. If I could say in a few words 
what would seem to me ideal first aid treat- 
ment it would be: 

(1) Expose the open wound widely, if 
necessary by cutting away the clothing 
around it. (2) Cover the wound with a 
sterile dressing. (3) Bandage it snugly to 
stop bleeding. (4) Immobilize the part by 
the simplest method available. (5) Get the 
patient to the doctor immediately. In 
other words protect the wound, but leave it 
alone. 

From that time on the care of the wound 
becomes the surgeon’s problem. His first 
responsibility is to determine as completely 
as possible the extent of injury, not by an 
examination of the wound, but of the pa- 
tient. There seems to be an overwhelming 
urge on the part of the unthinking individ- 
ual to examine the wound, to probe it or 
to put tension on injured structures. He 
must convince himself by seeing and feeling 
torn tissues that an injury has actually been 
sustained. The thoughtful surgeon knows 
that such examination is a waste of time, 
causes suffering and pain and rarely gives 
helpful information because of the distor- 
tion and discoloration of all the tissues in- 
volved. 

The questions one can usually answer 
with certainty from an examination of the 
patient are: 

(1) Has there been a fracture? (2) 
Has there been a nerve injury? (3) Has 
there been a tendon injury? 

To elicit the presence of sensation in the 
area of median nerve distribution, for ex- 

*From the Department of Surgery, Northwestern Uni- 
versity Medical School. Read before the Wayne County 
Medical Society, Detroit, Michigan, March 14, 1938. 

January, 1939 



Fig. 1. The sensory distribution of the median, ulnar, 
and radial nerves in the hand. Loss of sense of pain and 
touch indicates that there has been a crushing, tearing, or 
division of the nerve supplying the affected area. (Surg., 
Gynec. & Obst., 52:594, 1931.) 



Fig. 2. Adduction of the fingers toward the middle 
finger ( a), abduction of the fingers from the middle finger 
(b), and abduction of the thumb toward the hand (c) are 
carried out by the interossei, the muscles of the hypothenar 
eminence and the adductor pollicis, all of which are sup- 
plied by the ulnar nerve. (Surg., Gynec. & Obst., 52:595, 
1931.) 

ample, requires but a moment, but no 
amount of probing of a penetrating wound 
will give exact information as to the pres- 
ence or extent of such an injury (Figs. 1,3). 

Having determined the extent of injury, 
the next problem is care of the wound. The 
question as to the best method is a con- 
troversial one, but these facts, based on a 


27 


COMPOUND INJURIES— KOCH 


considerable experience, seem to me incon- 
trovertible : 

1. Injuries are often more serious than 
the hasty examiner suspects. 


2. Failure to prepare a sufficiently wide 
area about the site of injury and inadequate 
assistance often make it difficult to maintain 
good technic. 

3. A patient who suffers pain is difficult 
to control. Particularly when an extremity 
is involved he may make some sudden 
movement that completely nullifies one’s ef- 
forts to maintain a sterile field and to do 
accurate surgical work. 

4. Repair of injuries of the extremity 
requires a bloodless field; and maintenance 
of the required constricting pressure of 250 
mm. of mercury soon becomes extremely 
painful for the average patient. 

For these reasons we have come to adopt 
the following routine for all cases in which 
more than a simple cutting injury of super- 
ficial tissues has occurred. When the ex- 
amination is completed the patient is sent 
to the operating room, the blood pressure 
cuff which is to serve as a constrictor is 
applied and an anesthetic given. Nitrous 
oxide or ethylene is preferred. The mem- 
ber of the operating team who first finishes 
scrubbing his own hands prepares the field 
of operation. After putting on sterile gloves 
he washes a wide area about the site of 
injury with soft cotton, plain white soap 
and sterile water. The dressing over the 
wound is undisturbed until the area about 
the wound is cleansed. Then the dressing 
is removed and the wound itself carefully 
cleansed with soap and water until we are 


satisfied that it is as clean as it is possible 
to make it. If bleeding begins when cleans- 
ing of the wound is begun the arm is held 
up for a moment or two and the blood 



Fig. 4. (a) If the proximal phalanx of the thumb is held 
fixed, active flexion at the interphalangeal joint is due solely 
to the contraction of the flexor pollicis longus. If tendon 
is divided the thumb remains in extension, (b) After division 
of the flexor profundus; flexion at the proximal inter- 
phalangeal joint is possible if the flexor sublimis is still 
intact, but the finger remains extended at the distal inter- 
phalangeal joint. ( c) If the flexor profundus is intact the 
finger can be flexed at the distal interphalangeal joint. 
(Surg., Gynec. & Obst., 52:595, 1931.) 

pressure cuff inflated. The soapy solution 
is finally washed away with a generous 
amount of sterile salt solution. 

After the sterile linen has been arranged 
the operative procedure indicated is carried 
out. The ideal we constantly strive for is 
primary repair and closure of the wound. 
This is not always possible or wise; but it 
is my belief that if a patient is seen im- 
mediately after an injury has been sustain- 
ed, if the wound is not the result of a crush- 
ing injury, and if there has not been exten- 
sive loss of covering tissue, it is usually 
possible by patience, careful cleansing and 
gentle handling of tissue to convert a con- 
taminated wound into a clean wound, to re- 
pair the injured structures and close the 
wound (Fig. 6). 

Each of the conditions mentioned is im- 
portant. An open wound left untreated re- 
mains a contaminated wound for a few 
hours only. As bacteria invade the tissues 
the stage of infection develops. When in- 
fection has begun, any operative procedure 
beyond cleansing of the surface carries with 
it the risk of spreading infection widely 
and rapidly. Secondly, severe crushing 
wounds are not susceptible of immediate 
repair, for it is often impossible to deter- 
mine the extent of tissue damage at the first 
examination. Careful wound cleansing. 

Jour. M.S.M.S. 



Fig. 3. (a) Flexion at the metacarpophalangeal joints is 
produced by the lumbricals and interossei. (b and c) With 
injury or division of the median and ulnar nerves below the 
middle of the forearm the power of flexion at the metacar- 
pophalangeal joints is lost; the finger can still be flexed at 
the interphalangeal joints by the long flexor tendons. (Surg., 
Gynec. & Obst., 52:595, 1931.) 



28 


COMPOUND INJURIES— KOCH 


with immobilization and watchful waiting, 
is less likely to prove disappointing than 
the attempt to repair tissues whose vitality 
is in question. Thirdly, if the covering tis- 


procedure. It is better first to secure clo- 
sure of the wound, and when that objective 
has been accomplished to repair the deeper 
tissues. 



Fig. 5. (a) “Drop wrist” of musculospiral or radial nerve injury, (b) Loss of power 
of extension of the fingers due to injury or division of the extensor communis digitorum. 
(c) With the proximal phalanges supported, the fingers can be extended by the action 
of the lumbricals and interossei even though the common extensor is divided, (d) Loss 
of power of extension at the distal interphalangeal joint due to division of the ex- 
tensor tendon opposite the joint or avulsion of the tendon from its insertion on the 
distal phalanx. (Surg., Gynec. & Obst., 52:596, 1931.) 




Fig. 6. Result of immediate repair of injury which had 
caused complete division of median and ulnar nerves and 
of all the long flexor tendons of fingers and wrist. This 
patient wore the splint pictured constantly for a year after 
injury so as to avoid tension upon the lumbrical and inter- 
osseous muscles while regeneration of the divided nerves 
was taking place. 

sues have been lost as the result of avulsion 
or a shearing injury it is unwise to attempt 
repair of deeper structures, and then cover 
the open wound with grafts or by a plastic 

January, 1939 



Fig. 7. Incisions (dotted lines) for 
securing adequate exposure of injured 
structures. Solid black lines repre- 
sent wounds of common occurrence. 

Incisions should not be made across 
the wound which has resulted from 
the injury. 

It is hardly necessary to emphasize the 
fact that unless one is willing to exert every 
possible effort to cleanse the contaminated 
wound, to avoid trauma, and to carry out 
repair of injured tissues and closure of the 
wound with exacting care, it would be far 
better simply to cleanse the wound, im- 
mobilize the part, and permit healing to 
take place as rapidly as possible. Excellent 
results can still be obtained by repair after 
wound healing has taken place, but no 


29 




COMPOUND INJURIES— KOCH 


amount of surgical judgment or skill can 
compensate for the destructive and crippling 
effect of the infection which can so easily 
result from inadequate or indifferent treat- 


constriction of the blood pressure cuff is 
then released to make certain that no active 
bleeding is present. When bleeding is ar- 
rested the pressure is reapplied and contin- 



Fig. 8. Aluminum splint for maintaining hand and fingers in the position of function. It can be sterilized and 
incorporated in the dressings during the stage of acute inflammation; it can be covered with felt and provided with 
straps for easy application and removal during the stage of convalescence. (Internat. Abstr. Surg., Surg., Gynec. & 
Obst., p. 106, (Feb. 1) 1938.) 


ment immediately after an injury has been 
sustained. 

It is often necessary to enlarge the origi- 
nal wound to secure adequate exposure of 
injured tissues (Fig. 7). A transverse cut 
across a finger or across the wrist can be 
extended proximally from one side and dis- 
tally from the other, and so permit wide 
exposure by a simple extension of the 
original wound. A median incision over 
finger or wrist always leads to flexion con- 
tracture. If the surgeon’s incision crosses 
the wound of injury transversely it makes 
wound healing by primary union difficult of 
achievement. 

It is not necessary to discuss the exact 
technic of fracture reduction, of tendon re- 
pair and of nerve suture. I would simply 
say that when repair of the deeper tissues 
is to be carried out the structures affected 
are first identified and isolated so that one 
knows exactly what needs to be done. The 


ued until wound closure is complete and 
the pressure dressing applied. 

In repairing tendons we handle them 
gently, put tension on them only with moist 
gauze, and suture them with silk. Nerves 
are handled with the same care, and suture 
is carried out with the finest silk obtainable 
threaded on swaged needles. The suture 
catches only the perineurium and never en- 
ters the substance of the nerve. 

When repair of the deeper structures is 
complete the fascia is accurately united with 
fine silk sutures and the skin wound is 
accurately closed. No drains are left in the 
sutured wound. 

It has been suggested above that when 
loss of covering tissue has taken place re- 
pair of injured deeper structures should be 
postponed. Time and function, however, 
can be saved, and long continued infection 
and formation of crippling scar tissue 
avoided if such wounds are closed at the 


30 


Tour. M.S.M.S. 


CASE HISTORY 


primary operation. A graft of intermediate 
thickness, a full thickness graft or some 
type of flap may provide the best solution 
in any specific case, but, if it is in any way 
possible the wound should be closed, and 
without excessive tension. If relaxing in- 
cisions are made to permit skin edges to 
come together without tension the raw sur- 
faces left at the site of the incisions should 
be immediately covered with razor grafts 
and not left to heal by granulation and scar 
formation. 

Finally the injured part should be im- 


mobilized in such a position as to relieve 
tension on injured tissues and put them at 
rest. Just as fractured bones, fractured 
tendons, nerves and soft tissues require re- 
duction and immobilization in such a posi- 
tion that no undue strain is put upon any of 
the fragments (Fig. 8). Unless this is 
done, and particularly with fractured ten- 
dons, either the suture will give way com- 
pletely, or it will cut through the ends of 
the tense tissue; in either case separation 
takes place and no helpful result is ac- 
complished. 


CASE HISTORY 

It is suggested that the reader peruse this case history carefully; come to his own 
conclusions, and then turn to page 56 for a discussion of the same. 


History . — G. P., a married white woman, aged 
twenty-nine, entered University Hospital on August 
30, 1938, complaining of pain when she moved her 
eyes, and swelling of the eyelids. On two occasions 
early in August, 1938, she had sampled liberally of 
uncooked meat loaf containing pork. On August 26, 
she noted burning of the eyes and a headache. 
Two days later it was difficult for her to move her 
eyes because of pain and the following day (August 
29) her eyelids became “swollen shut.” Chronic 
constipation was present at the time of admission. 

The systemic, past and family histories were not 
contributory to her present illness. 

Physical Examination. — Physical examination at 
the time of admission revealed a well developed and 
well nourished white woman who appeared moder- 
ately ill. Her temperature was 101.8, pulse 120, and 
respirations 30 per minute. There was moderate 
edema of the eyelids bilaterally ; most marked above, 
this was also present in the conjunctivae. The oph- 
thalmoscopic examination showed no abnormalities. 
There were hypertrophic septic tonsils. The chest 
and heart examinations were not abnormal. There 
were no palpable abdominal visceral enlargements. 
Muscular tenderness was not demonstrable. Neu- 
rological examination was normal. 

Laboratory Data. — The blood Kahn reaction was 
negative. The urine showed no abnormalities. The 


admission blood studies showed a hemoglobin 88 
per cent (Sahli) ; R.B ; C. 4,410,000; W.B.C. 10,900 
and a differential of 75 per cent neutrophils, 5 per 
cent eosinophils, 18 per cent lymphocytes, and 2 
per cent monocytes. Subsequent blood studies show- 
ed a rise of the eosinophils to 37 per cent with a 
21 per cent value at the time of discharge, the total 
W.B.C. being 8,500 at that time. No parasites were 
found in the stools. The blood sedimentation rate 
was slightly elevated on admission but fell to normal 
before discharge. The skin test with trichina anti- 
gen (1-10,000) showed a positive reaction within 
five minutes. The blood precipitin reaction for 
trichiniosis was positive up to and including dilu- 
tions of 1 :800. E.K.G. examinations were not ab- 
normal. 

Clinical Course. — On September 9, there was sore- 
ness of the muscles of her neck, upper and lower 
extremities, at which time the edema of the eyes 
had disappeared. Her temperature ranged be- 
tween 101 and 102.8, falling by lysis and reaching 
normal by the 13th hospital day. Before discharge 
a tonsillectomy was performed. The microscopic 
examination of the pharyngeal muscle tissue ob- 
tained showed small foci of interstitial myositis with 
areas of eosinophilic infiltration as well as encysted 
trichinae. At the time of discharge she was entirely 
asymptomatic. 


HISTORICAL ASPECTS OF IRON THERAPY IN ANEMIA: 
CHAIRMAN’S ADDRESS 

While iron has been prescribed for almost three centuries, its therapeutic use is far older 
than the rational explanation of its action, and opinion concerning its value has changed 
greatly from time to time. Russell L. Haden, Cleveland ( Journal A.M.A., Sept. 17, 1938), 
reviews the most pertinent clinical literature on the subject. The most recent development 
in iron therapy has been the renewed emphasis on the greater potency of ferrous salts. While 
any iron preparation is effective if given in large enough doses, very much less of the 
ferrous compounds needs to be taken. Thus the two fundamental principles of iron therapy, 
large doses and the use of a ferrous salt, now generally accepted, only confirm what Blaud, 
Niemeyer, Immerman, Osier and others thought and practiced. These principles, forgotten 
by clinicians for many years, have only recently been learned anew. Such rediscoveries 
emphasize again our debt to the great clinicians of the past. 

January, 1939 


31 


TREATMENT OF SOME COMMON DISEASES OF THE SKIN* 

HOWARD FOX, M.D. 


Emeritus Professor of Dermatology and Syphilology 
New York University College of Medicine 

NEW YORK CITY 



Howard Fox 


The following remarks on the treatment of diseases of the skin may 
not accord fully with the views of some of my colleagues, as they are 
based almost entirely on personal experience. My discussion will in- 
clude the treatment of some inflammatory diseases, infectious gran- 
ulomas and pyogenic infections. 

Acne vulgaris responds well to treatment as far as disappearance 
of the lesions is concerned. I know of no satisfactory method, how- 
ever, of treating pitted scars that occur in the severe cases. In at lea'st 
85 per cent of the cases, a permanent cure can be obtained by frac- 
tional doses of roentgen rays, given at weekly intervals for three to 
It is always advisable to 


four months, 
warn the patient that, after such therapy, 
scars may be present and that these are due 
to the disease itself and not to the treatment. 
Ultraviolet therapy is of some value in 
persons who tan easily, but its effect is 
more or less temporary. Soap frictions and 
sulphur lotions, combined with mechanical 
methods, are time-honored • procedures 
which suffice for the treatment of mild 
cases. Vaccine therapy, in my opinion, is 
worthless, though such treatment is still 
widely employed by the general practitioner. 
Diet is also of little value. Hormonal ther- 
apy is theoretically indicated but up to the 
present its results have been unsatisfactory. 
It is still in the experimental stage. 

Rosacea is a common disease, especially 
in women, and requires internal treatment 
primarily. It occurs mainly in persons of 
middle age who lead a sedentary life and 
particularly those who suffer from indiges- 
tion. A trial of dilute hydrochloric acid is 
always indicated and is followed, at times, 
in several weeks by astonishing improve- 
ment or recovery. The general treatment 
can be summarized by getting the patient 
into the best possible physical condition, into 
“training” in other words. 

The severe type of rosacea (rhinophy- 
ma), consisting of large hyperplastic nodu- 
lar swellings of the nose, occurs entirely in 
men. It is not necessarily due to the ex- 
cessive use of alcohol, though this is often 


“Read before the Seventy-third Annual Meeting of the 
Michigan State Medical Society, Detroit, September 22, 
1938. 


an important cause. The milder types of 
rhinophyma can be improved by scarifica- 
tion, though few patients are willing to sub- 
mit to this treatment. It produces results, 
however, without appreciable scarring. The 
large noses with lobulated masses, can be 
destroyed by electrodesiccation under local 
anesthesia, or can be surgically excised un- 
der general anesthesia. The nose is prac- 
tically whittled down like a stick to the nor- 
mal size and healing takes place in about 
five weeks without the intervention of skin 
grafting. 

For the treatment of poison ivy derma- 
titis, nearly every physician has his pet rem- 
edy, the chief value of which is to lessen 
itching and edema. These remedies do not 
materially shorten the course of this self- 
limited disease. Immediately after expo- 
sure to one of the poisonous rhus plants, 
soap containing free alkali, such as laundry 
soap, is indicated for the hands or other 
parts which have come in contact with the 
plant. Later, cold, wet dressings of boric 
acid are useful to reduce swelling, after 
which the ordinary calamin lotion (using 
pure lime water and no phenol) can be 
applied. While the disease cannot be abort- 
ed as a rule, prophylactic treatment has, I 
think, been proven to be of value. This 
can be given as intramuscular injections of 
poison ivy extract for several doses at in- 
tervals of a few days or the tincture of 
rhus toxicodendron may be given by mouth, 
beginning with a few drops and increasing 
daily till a dram is reached. The patient 

Tour. M.S.M.S. 


32 


COMMON DISEASES OF THE SKIN— FOX 


may then continue to take a teaspoonful of 
the drug once daily during the poison ivy 
season. 

The treatment of bromoderma is a simple 
matter as soon as the correct diagnosis is 
made. If the characteristic acneform pus- 
tules or granulomatous masses are suspected 
of being due to bromides, the suspicion may 
often be confirmed by a history of having 
taken the drug. Many patients do not con- 
sider soda fountain remedies to be drugs 
and it is always wise to ask directly whether 
bromo-seltzer has been taken. I have pho- 
tographs of two severe cases of bromoderma 
due to long-continued use of this nostrum. 
In one case the eruption had been present for 
four years without recognition of its true 
nature. Withdrawal of the drug is followed 
by disappearance of the eruption, though 
this is often slow. To expedite a cure, the 
patient may be given physiologic salt solu- 
tion intravenously in doses of 100 c.c. at 
intervals of a few days, three or four times. 
This procedure also makes it easier to dem- 
onstrate bromine in the urine. 

A single attack of herpes simplex, wheth- 
er on the lips or genitals, is of little conse- 
quence. When, however, the disease re- 
curs every few months for years, it becomes 
a problem of some importance. I have re- 
cently seen a woman who had had recurring 
attacks of herpes of the neck four times a 
year for twenty years. Each attack was 
accompanied by three or four different 
groups of vesicles. A simple method of 
treating such cases consists of inoculations 
of smallpox vaccine once a month for four 
consecutive months. In a reasonable num- 
ber of cases this method is successful, fa- 
vorable results occurring whether or not 
the vaccine “takes.” In a report to be pub- 
lished later, Dr. Richard Kelly states that 
he has been able to abort attacks of herpes 
by intradermal injections of Moccasin snake 
venom. He also found that the attacks 
were less frequent after this treatment. In 
a few cases of recurrent herpes, I have seen 
a complete cessation of attacks after several 
roentgen-ray exposures confined to the af- 
fected areas of the skin. 

Herpes zoster is a self-limited disease 
which rarely recurs. I know of no means 
by which its course can be shortened. All 
we can do is to lessen pain, attempt to pre- 
vent scarring and pay close attention to the 
cases which affect the eye (herpes ophthal- 

Tanuary, 1939 


micus). Zoster apparently causes no pain in 
children under ten years of age. Pain is 
often severe in elderly people and may per- 
sist even for years after disappearance of 
the eruption. I have seen some favorable 
results in controlling pain by the use of 
pituitrin, though my experience with intra- 
venous use of iodides as recommended by 
Ruggles has not been satisfactory. Years 
ago I found that pain could be controlled 
by paraffin sprayed on the affected skin by 
a special atomizer or simply dabbed on the 
parts, which were then covered by a volumi- 
nous layer of absorbent cotton held in place 
by a bandage. In the cases which I report- 
ed, the pain was usually relieved at the end 
of 24 to 48 hours. Caution was necessary, 
however, in removing the cotton to avoid 
rupture of the vesicles. Zoster ophthalmicus 
is always alarming, though it is rarely fol- 
lowed by permanent injury to the eye. Ev- 
ery case of this type should be seen by a 
competent ophthalmologist. 

In treating psoriasis, one may often ob- 
tain temporary results, though it is always 
difficult, in extensive cases, to remove every 
vestige of the eruption. The treatment can 
be summed up by the words “soap and 
water, grease and sunshine.” Curiously 
enough, some physicians do not realize that 
soap and water are nearly always indicated 
in psoriasis, especially for removal of scales. 
The best remedy is natural sunshine for 
persons who are able to acquire a tan. As 
long as the skin remains tanned, such per- 
sons will be largely free from psoriasis. 
Unfortunately, ultraviolet rays from artifi- 
cial sources are not as efficacious as the 
sun’s rays. A fairly satisfactory method, 
however, of using ultraviolet rays from 
quartz lamps, consists of an application of 
crude coal tar at night, which is then re- 
moved, followed the next day by irradiation 
(Goeckerman method). Among the vari- 
ous reducing drugs, chrysarobin has held a 
high place for many years and is best used 
in ointment form. Whenever an intensive 
action is desired, the ointment should be ap- 
plied to the skin and covered by an imper- 
meable substance, such as oiled silk. This 
is specially indicated for thickened patches 
on the legs, where even prolonged exposure 
to the sun’s rays may not cause the patches 
to disappear. The use of chloroform or 
traumaticin as vehicles for chrysarobin is 
much less efficacious than ointments (of 


33 


COMMON DISEASES OF THE SKIN— FOX 


vaseline or lanolin). For the past few 
years, I have used the proprietary remedy, 
anthralin, rather extensively and prefer it 
to chrysarobin. It has been found by Corn- 
bleet to be a stronger reducing agent and is 
somewhat less disagreeable than chysarobin. 

Lupus erythematosus is still an obstinate 
disease to treat, though the introduction of 
gold salts has somewhat simplified the prob- 
lem. The favorite preparation in this coun- 
try is gold sodium thiosulphate, the initial 
dose of which should be 5 to 10 mg. The 
maximum dose should never exceed 50 mg. 
in my opinion, if disagreeable reactions are 
to be avoided. The drug is given intrave- 
nously at weekly intervals for weeks or 
months, if necessary. Small areas, which 
are refractory to intravenous therapy may 
be treated intradermally, as suggested by 
Traub and Monash, the results being sur- 
prisingly good at times. Intramuscular in- 
jections of bismuth may be used in place of 
gold salts, but in my experience their action 
is slower and somewhat less satisfactory. 
My results with quinine bisulphate, in a 
small number of cases, have been disap- 
pointing. The aforementioned methods ap- 
ply only to the fixed type of the disease. 
The treatment of the disseminate type of 
lupus erythematosus is unsatisfactory. 

The treatment of pemphigus vulgaris in 
adults is extremely discouraging as the dis- 
ease is nearly always fatal within three to 
eighteen months after onset. New remedies 
have been enthusiastically suggested from 
time to time but have thus far been dismal 
failures. The Davis method of giving ar- 
senic and an extract of blood platelets on 
alternating days and treatment by large 
doses of viosterol have largely been discard- 
ed. The profession is now experimenting 
with germanin, a drug that is dangerous, 
especially from its action on the kidneys. 
I have not been favorably impressed with its 
use in pemphigus. The best local treatment 
consists of greasy applications, such as boric 
acid ointment. The dry method of using 
dusting powders usually fails. Until we 
know more about the disease, which is pos- 
sibly due to a filterable virus, pemphigus 
will continue to be largely a problem of 
nursing. 

Sycosis vulgaris, of staphylococcic type, 
has long been the bete noir of dermatolo- 
gists. Even epilation by roentgen rays fails 
to cure some of the cases. The recent intro- 


duction of the proprietary remedy, com- 
pound quinolor ointment (Squibb) has en- 
abled us to cure many cases of this obsti- 
nate disease. It is often necessary to con- 
tinue the use of this ointment for months 
after the disappearance of the eruption, due 
to its tendency to relapse. This remedy 
is also of value in cases of staphylococcic 
folliculitis that occur on the limbs, especially 
in hairy persons. If sycosis vulgaris 
(bearded region) is to be treated by roent- 
gen rays, this agent should be applied in 
epilating doses. The practice of giving a 
series of a dozen or fifteen fractional doses 
at weekly intervals is usually followed by 
failure. 

Of the various types of tuberculosis of 
the skin, lupus vulgaris, as its name implies, 
is the commonest. It is a serious disease, due 
to its chronicity, its tendency to disfigura- 
tion and its possibility of dissemination, and 
death. Lupus is poorly treated in this coun- 
try, due to the lack of special hospitals 
similar to the Finsen Institute abroad. The 
mercury vapor quartz lamps are, unfortu- 
nately, poor substitutes for the large Finsen 
lamps. When the disease is seen early and 
consists of one or two small patches, the 
proper treatment, in my opinion, is exci- 
sion. Great improvement, though not a 
cure, may be obtained by a salt-free, high- 
vitamin diet. The roentgen rays are useful 
in hypertrophic and ulcerating types of lu- 
pus vulgaris and also for scrofuloderma and 
the verrucous type of cutaneous tuberculosis. 
The best treatment for papulonecrotic tu- 
berculide is the administration of antisyphi- 
litic remedies, including arsphenamin or al- 
lied drugs and bismuth. This is highly rec- 
ommended by Darier, with whose opinion I 
heartily concur. 

The treatment of a furuncle should in- 
clude advice to the patient not to squeeze or 
otherwise traumatize the lesion. One of 
my patients, suffering from two large boils 
of the face, disregarded this advice and, as 
a result, suffered from a metastatic abscess 
of the prostate gland, which occasioned an 
illness of two months’ duration. Attempts 
to abort furuncules have rarely been suc- 
cessful in my experience. For the treat- 
ment of a succession of boils (furunculosis') 

I always advise a trial of vaccine therapy. 
In my experience, this has usually been suc- 
cessful when properly carried out. The 
proper procedure is to use a tuberculin 

Jour. M.S.M.S. 


34 


COMMON DISEASES OF THE SKIN— FOX 


syringe and give one minim as the initial 
dose, gradually increasing doses to be given 
every five days, for eight to ten injections. 
If new boils appear during the course of 
treatment, the dosage should be lowered. 
Furthermore, I think stock vaccines are usu- 
ally as efficacious as autogenous ones. I 
am now convinced that dietetic treatment 
has little or no value, except in frank cases 
of diabetes. It is rare to find any change 
in the sugar content of the blood in the 
vast majority of cases of furunculosis. In 
fact, satisfactory results were obtained by 
Tauber in a large series of patients who 
were purposely given a high carbohydrate 
diet. 

Impetigo contagiosa is most often treated 
in this country by ammoniated mercury oint- 
ment in 5 to 10 per cent strength, although 
some persons are sensitive to this drug. 
Under any circumstances, this should not be 
used immediately before or after iodine has 
been applied as the resulting mercuric iodide 
is extremely irritating to the skin. Painting 
the areas (after removal of crusts) with sil- 
ver nitrate is effective but temporarily dis- 
figuring. The same is true of various dyes 
such as gentian violet and brilliant green 
(1 per cent aqueous solution). Alibour 
water is highly recommended by Darier and 
consists of copper sulphate grm. 2, zinc 
sulphate grm. 7 in camphor water, grm. 300. 
A tablespoon of this stock solution is added 
to a glass of water for external application 
every hour. This remedy is effective 
though its application is somewhat time- 
consuming. 

Sulfanilamide has proven to be an inval- 
uable remedy for erysipelas and has en- 
tirely supplanted the use of anti-streptococ- 
cic serum for the treatment of erysipelas 
in Bellevue Hospital. A voluminous liter- 
ature has already appeared on the use of 
this new contribution to chemotherapy. 
Striking results were recently reported by 
Chargin from the use of sulphanilamide in 
chancroid. In my recent service in Belle- 
vue Hospital, I also observed some astonish- 
ingly good results, particularly in chronic 
phagedenic types of this disease. 


The treatment of common warts would 
supposedly be an easy matter. This is by 
no means true if the lesions are to be re- 
moved with little or no scarring or pain. 
Roentgen rays are successful in only a mi- 
nority of cases, but are worthy of trial when 
the lesions involve the nail folds. I am 
opposed to treating common warts by elec- 
trodesiccation, which is apt to leave scars. 
The best method, I think, is to freeze the 
lesion with ethyl chloride spray and then 
remove it by a sharp bone curette. The 
wart is removed en masse with little or no 
scarring. The curette is also useful in re- 
moving juvenile flat warts, which also occur 
not infrequently on the bearded region of 
men. The idea that verrucse might be 
caused to disappear by mental suggestion 
has been scientifically proven in a large se- 
ries of cases by Bloch. It seems incredible 
that an organic lesion, known to be due to 
a filterable virus, could be influenced solely 
by the mind. I have sometimes been an- 
noyed after favorable results by the roent- 
gen ray treatment to think that they may 
have been merely due to suggestion in an 
impressionable person, such as a child. Ju- 
venile flat warts often disappear in a few 
weeks after oral administration of protio- 
dide of mercury, J4 grain tablets two or 
three times a day. My successes with this 
method have been mostly confined to young 
patients. 

As alopecia areata is a rather capricious 
and self-limited disease, it is difficult to 
evaluate remedies used for its treatment. 
I feel convinced, however, that intensive 
local stimulation is worth a trial, except in 
cases of complete loss of hair. Small 
patches may be painted every two weeks 
with pure phenol until they are white. For 
the more extensive areas, the mercury vapor 
quartz lamps offer a convenient and cleanly 
method of stimulation. Irradiation should 
always be given to the point of an ery- 
thema, followed by desquamation. I am 
thoroughly convinced, and my dermato- 
logic colleagues will agree with me, that 
antuitrin is of no value in the treatment 
of alopecia areata or, in fact, any other 
type of baldness. 


January, 1939 


35 


POLIOMYELITIS IN KENT COUNTY: STATISTICAL SUMMARY 


WILLIS DIXON, M.D., and CHARLES FRANTZ, M.D. 

GRAND RAPIDS, MICHIGAN 


The outbreak of anterior poliomyelitis in Kent County during the late summer of 
1935 was more extensive than in previous years. During the latter part of August and 
the early days of September, we were able to study thirty-eight cases. These cases were 
hospitalized and carefully watched over a period of two and one-half years. 

On entrance the patients were placed in isolation. Complete blood and spinal fluid 
studies were made. Following the period of isolation and cessation of the acute stage, 
muscle tests were made and the group was periodically reexamined. The following out- 
line summarizes the study: 


Morbidity. — All cases occurred within a 
three-week period, the peak arriving on the 
sixth day. Following this day there was a 
slow but gradual decrease. The period ex- 
tended from August 12 to September 2 

(Fig. 1). 



Distribution.— C ases occurred equally in 
urban and rural areas. In two instances 
two members of a family presented symp- 
toms. 

AGE INCIDENCE 

OLDEST 35YRS. YOUNGEST 2 . YRS. 

30-35p* 

25-30 ■ 

20-25p^H 

I5-20BBH 

5-IO^HH 

Fig. 2 

Age Incidence. — Most cases occurred be- 
tween the ages of five and ten years. The 
oldest case reported was thirty-five 3 ^ears ; 
the youngest, two years (Fig. 2). 

36 


Complaint. — The complaints of the pa- 
tient were carefully recorded, and in the 
young children the parents were thoroughly 
questioned as to the type of onset. The 
following complaints are recorded in the 
order of frequency: 


Headache 26 

Generalized aching 20 

Nausea 16 

Stiff neck 14 

Sore throat 13 

Restlessness 13 

Constipation 6 

Difficult breathing — Diaphoresis. 3 

Vomiting 2 

Diarrhea 2 

Photophobia 1 


From this list one can readily see that 
headache and general malaise were almost 
a constant complaint. 

C linical Examination . — 


Injected throat 25 

Rigidity of neck 24 

Rigid spine 20 

Positive Kernig 12 

Hyperactive knee jerks 12 

Loss of abdominal reflex 8 

Loss or weakness of knee jerks 8 

Loss of muscle power 6 

Lethargy 5 

Muscle tenderness 3 

Diaphoresis 3 

Abdominal breathing (no inter- 
costal excursion) 2 

Photophobia . . 1 


The highest temperature recorded on ad- 
mission was 103 degrees, the lowest, 98 de- 
grees. The average range of temperature 
was five degrees. At no time was there a 
temperature above 103 degrees. The high- 
est pulse rate was 140, which was recorded 
in a case of intercostal paralysis. This case 
also carried a respiratory rate of 40 per 
minute. 

Laboratory Findings. — The white blood 
counts varied considerably. The lowest was 
3,299 with a normal differential. The higli- 

Jour. M.S.M.S. 


POLIOMYELITIS IN KENT COUNTY— DIXON AND FRANTZ 


est recorded was 17,200 with the polymor- 
phonuclear cells at 80 per cent and the 
lymphocytes at 17 per cent. The average 
white blood cell count was 9,365. The spi- 
nal fluid counts were as variable as the 
blood pictures. The lowest cell count was 
eight cells, and the highest 1,060 cells. The 
greater number of cases ran counts between 
50 and 100 cells (Fig. 3). 


were immediately isolated and subjected to 
a spinal puncture and blood study. Sand- 
bags and plaster of Paris splints were used 
where necessary. The patients received 50 
to 400 c.c. of convalescent serum in divided 
doses. A few patients having paralysis on 
admission were not given serum. All pa- 
tients were kept flat until the isolation pe- 
riod was up. They were then given muscle 


SPINAL FLUID COUNT 



Fig. 3 


Globulin was positive in twenty-three 
cases. The sugar content did not show 
any marked reaction. The lowest reading 
was 42 milligrams; the highest, 71.5 milli- 
grams. In twenty-three cases the lympho- 
cytes predominated over the polymorpho- 
nuclear cells in a ratio of two to eight. The 
remainder of the cases revealed the neutro- 
philes predominating over the lymphocytes 
in a ratio of 5.5 to 4.5. 


SEVERITY OF WEAKNESS 



Fig. 4 


tests depending upon their general condi- 
tion. Those cases in which there was pain 
were not examined until cessation of muscle 
tenderness. 

Distribution of Weakness . — It is extreme- 
ly difficult to record in chart form the dis- 
tribution of weakness. The lower extremi- 
ties, back, and abdominal musculature pre- 
dominated. Two cases of intercostal paraly- 
sis also presented weakness in the lower 
extremities. 

Seventy of Weakness . — After the cessa- 
tion of the acute stage, the cases were arbi- 
trarily classified as normal, mild, moderate- 


PRESENT STATUS 


J OUT of Centro/ "Z6.Z% 


D/scta.y'oe d V7Z% 


Su Pcrv/S/on /d.7% 
77-cai^e^ t~ J?>.2 9c 
* 7 ] Oee^d 2.C7, 


Fig. 5 


In endeavoring to correlate the spinal 
fluid count with the white blood cell count, 
no constant data could be recorded. In the 
majority of cases both the white blood cell 
count and the spinal fluid count were in- 
creased, but in no definite ratio. In one 
case the white cells of the blood numbered 
12,450 per cubic millimeter and the spinal 
fluid cells numbered 296; in another, the 
blood cells were relatively normal and the 
spinal fluid counted 275 cells. 

Treatment . — On admission all patients 

January, 1939 


ly severe, and severe. The moderately 
severe cases have shown improvement and 
are periodically examined. The severe 
cases are still under active physiotherapy 
and continue to wear braces (Fig. 4). 

Present Status . — Ten patients failed to 
return for reexamination. Eighteen pa- 
tients were discharged from further care 
after a year of periodic examinations. Four 
patients are being reexamined every few 
months, particularly to watch for limp and 
scoliosis. This latter condition develops in- 


37 


BONE MARROW— STERN 


sidiously in children with a back involve- 
ment even though it be mild. Five patients, 
two of whom are adults, continue to wear 
braces and are under active physiotherapy 
treatment. One patient of the bulbar type 
died in the acute stage of the disease (Fig. 
5 ). 

Comment 

Nothing unusual or new is evolved from 
studying this small group of cases. How- 
ever, the list of complaints and findings 
bring to mind the multiplicity of signs and 
symptoms presented in this disease. In a 
number of cases the diagnosis was question- 
able. We treated all cases as acute anterior 
poliomyelitis until proven otherwise. No 
case was finally diagnosed as encephalitis. 

It is of interest to note the fallacy of the 


term “Infantile Paralysis.” Only in a very 
small per cent of the cases was paralysis 
present, and of these two adults were in- 
cluded. 

One patient complained of a worm-like, 
hot, boring sensation under the skin, for a 
period of two weeks. This implied to us 
inflammation of the posterior horns of the 
spinal cord and a poor prognosis for the 
return of muscle function. This individual 
still has one flail arm and hand and a very 
weak shoulder girdle on the opposite side. 

Rest in bed is essential. Patients were 
kept flat from four months to a year, de- 
pending upon the severity of the involve- 
ment. During the acute and early convales- 
cent stages, the position of physiological rest 
was maintained by sandbags and plaster 
splints. 


THE BONE MARROW FROM A CLINICAL DIAGNOSTIC 

VIEWPOINT* 

LOUIS D. STERN, M.D. 

DETROIT, MICHIGAN 

It is common knowledge that the concept of diseases of the blood has changed. As a 
purely descriptive title this term has served for many years to include a group of diseases 
characterized by changes in the cellular elements of the circulating blood. But with the 
impetus given by the discovery of the anti- anemic principle in liver and the investigation 
of its action, attention has been directed more and more from the peripheral blood to- 
ward the hematopoietic tissues, and particularly to the bone marrow. The so-called dis- 
eases of the blood are now fairly well understood to be really diseases of the blood-form- 
ing organs. 

More detailed knowledge of the anatomy 
and physiology of these organs would throw 
additional light on the pathology of the 
disorders affecting them, and would aid ma- 
terially in diagnosis. But it is only within 
very recent years that such knowledge of 
the marrow has been obtained, and it is 
still imperfect. Less than ten years ago, 
authoritative writers referred to the lack 
of definite knowledge of the normal anatomv 
and physiology of the bone marrow, but as 
the result of their researches , 6 ’ 7 and others, 
a fairly comprehensive understanding has 
been attained. The prompt application of 
this knowledge to the study of disease states 
indicates how much it was needed; and the 
result has been that we now regard many 


*Read before the Seventy-second Annual Meeting of the 
Michigan State Medical Society at Grand Rapids, Septem- 
ber, 1937. 

P 


hematological disorders more rationally, and 
treat them more intelligently. 

The bone marrow may ' profitably be re- 
garded as a definite organ , 2 although it is 
spread throughout the skeleton. In infancy 
red, cellular marrow fills the medullary 
cavities of all the bones, but in a few years 
fat begins to appear. At about the age of 
twelve to fourteen years a patch of fat de- 
velops in the middle of the shaft of the 
long bones, and this gradually enlarges until 
in the adult there remains only one small 
area of red marrow near the upper end of 
the diaphysis. Red marrow continues to 
occupy the ribs, vertebrae, sternum, skull 
and the innominate bone throughout life, 
and the fatty marrow of the long bones 
may be quickly reconverted into function- 
ing, cellular tissue in response to increased 
demand or by disease. 


Jour. M.S.M.S. 


BONE MARROW— STERN 


The size of the marrow is not generally 
appreciated. There is, roughly, half as 
much total marrow as there is circulating 
blood, and of this about half is red and half 
yellow or fatty. The red marrow alone is 
approximately equal in weight to the liver, 
and the reserve of fatty marrow makes pos- 
sible an actual doubling in size. The ca- 
pacity of the normal marrow to produce 
cells is enormous ; it is estimated that in a 
healthy adult the output of red cells is 
about 900 billions daily. 3 

Microscopically, the great variety of mar- 
row cells and their seeming lack of organiza- 
tion might cause one to wonder how any 
orderly cycle of development could be dis- 
covered. The marrow, unlike most other 
organs, is not composed of fully differen- 
tiated cells already adapted for their func- 
tion, but contains primitive, undifferentiated 
forms which are constantly maturing and 
passing out into the blood stream. Al- 
though a detailed account of their develop- 
ment is out of place here, some considera- 
tion of this process is necessary for an un- 
derstanding of the changes which are recog- 
nized in disease. Investigators have simpli- 
fied the problem somewhat by selecting for 
study, situations in which new islands of 
hemogenesis appear in the fat, so that the 
number of cells is relatively few. Thus 
Sabin studied the developing chick embryo, 
and Peabody the erythropoiesis following 
infection. 

The basic structure and growth of the 
marrow is simple, in spite of the appear- 
ance of the ordinary microscopic section. 
There are only two varieties of cells to be- 
gin with — endothelial cells, which form the 
capillaries, and reticulum cells, which form 
a fine inter-capillary network and sinusoidal 
spaces. All of the developing blood cells 
arise from one or the other of these. The 
so-called fat cells of the marrow are not 
cells at all in the physiologic sense, but 
merely reticular spaces filled with coalesced 
fat droplets. In the erythrocyte series, the 
youngest cell which can be differentiated is 
the erythrogonia, which is too immature 
to show hemoglobin. In succeeding genera- 
tions it presents the features of the eryth- 
roblast, megaloblast, normoblast, reticulocyte 
and finally the mature erythrocyte. Release 
of erythrocytes into the circulation occurs 
normally at about the end of the reticu- 
locyte stage, as is evidenced by the presence 

January, 1939 


of about 1 per cent of these cells in the 
circulating blood. In health the bulk of 
erythropoietic tissue is made up of cells at 
the normoblast level with relatively few 
of the younger forms. But the latter have 
almost unlimited capacity for proliferation 
under abnormal conditions. 

In the granulocyte series, the youngest 
cell which can be differentiated is the mye- 
loblast. By nuclear and cytoplasmic changes 
it becomes successively a premyelocyte, mye- 
locyte, metamyelocyte, non-segmented poly- 
morphonuclear and, finally, a mature seg- 
mented polymorphonuclear. Delivery of 
granulocytes into the circulation occurs nor- 
mally just before and during the final lobu- 
lation process in the nucleus, so that the 
peripheral blood shows cells with varying 
nuclear forms, but only a small number of 
the younger non-lobulated class. The ma- 
jority of the developing granulocytes in the 
marrow are in the myelocyte and metamye- 
locyte stages, with relatively few of the very 
young forms. But again, these young cells 
have tremendous capacity for proliferation 
under abnormal conditions. 

In addition to erythrocytes and granulocy- 
tes the marrow contains small numbers of 
the other blood cells — lymphocytes and 
monocytes; also megakaryocytes — the par- 
ent cell of the blood platelets — and a few 
plasma cells. Any of these may proliferate 
to abnormal proportions in disease. Wheth- 
er or not lymphocytes and monocytes are 
normally produced in the marrow in any 
significant numbers is a debated question, 
and unimportant for the purposes of this 
discussion; pathologically they are so pro- 
duced. 

Ordinarily, the peripheral blood reflects 
fairly accurately the state of the marrow. 
Increased cells in the circulation denote 
greater marrow activity, and decreased cells 
the opposite. Usually some change in the 
average cell maturity accompanies altered 
numbers. Thus, the ordinary leukocytosis 
is characterized by more young polymor- 
phonuclears or non-segmented forms. But 
there is a definite threshold for cell deliv- 
ery which prevents cells normally confined 
to the marrow from overflowing into the 
circulation. This is a distinctly separate 
mechanism from the process of cell forma- 
tion and definitely separates the circulating 
blood cells from their tissue of origin. Very 
little is known of the factors which main- 


39 


BONE MARROW— STERN 


tain the normal levels of the circulating cells 
beyond the fact that they are concerned with 
many of the general physiological processes 
of the body, and particularly with certain of 
the glands of internal secretion. Cell deliv- 
ery may be materially changed, as, for ex- 
ample, in pernicious anemia and in the leu- 
kemias, where very immature cells reach the 
blood stream. Clinically this is important 
because the question as to how closely the 
peripheral blood reflects the state of the 
marrow depends very largely upon whether 
this “release factor” is effective or not. 

Comparative data concerning the blood 
and the marrow indicate that in most of 
the major hematological disorders there is 
a definite correlation between the two. 
That * is, a characteristic marrow picture 
exists as a counterpart of the blood picture. 
From experience, the state of the marrow 
in a given case may be inferred from the 
changes in the peripheral blood, but such 
inference will be accurate only insofar as 
the delivery of cells from the marrow oc- 
curs as assumed. It is obvious that when 
cells are retained in the marrow, no proof 
or even suspicion of their existence can be 
obtained from the blood. Although this sit- 
uation is not common, it occurs often 
enough both with normal and abnormal 
cell forms to cause important diagnostic 
difficulties. It is the experience of every- 
one who sees many of the so-called blood 
dvscrasias that some patients show little or 
nothing in the ordinary blood study upon 
which to base a diagnosis, yet the symptoms 
and signs of serious disease are definite. It 
is no longer good medical practice to label 
such a case as “severe anemia” or “splen- 
omegaly” or whatnot without trying to gain 
additional information from the bone mar- 
row. 

It is well to bear in mind that the ordi- 
nary blood study (cell counts, et cetera) is 
actually a biopsy, although a very simple 
one. The object is to study cellular struc- 
ture and relations just the same as in any 
other tissue removed from the body. To 
carry out a similar procedure on the parent 
tissue of the blood is a logical step toward 
detecting disease at its probable source. For 
clinical purposes the actual technic is sim- 
ple, 8 requiring no more skill or equipment 
than that needed for lumbar puncture, 
which operation it very much resembles. 

Since the sternum contains functioning. 


red marrow throughout life, and is more- 
over easily accessible, it is the most suitable 
place for obtaining marrow. A short, 
heavy, spinal puncture needle is a satisfac- 
tory instrument, although specially designed 
needles may be found more convenient. The 
anterior cortical layer of bone is easily pene- 
trated after local anesthesia, being only 
about 1 to 2 mm. thick. The marrow cav- 
ity is about 1 to 1^ cm. deep and if en- 
tered at an angle, offers plenty of leeway 
to avoid penetrating the posterior cortex. 
The marrow is fluid and easily aspirated 
into a syringe; but a very small amount 
(only 1 or 2 c.c.) should be withdrawn so 
as to avoid dilution by inflowing blood. The 
marrow so obtained is immediately mixed 
with an anticoagulant and from it thin 
smears are made which can be stained and 
studied exactly like those from blood. In 
fact, any of the procedures used for blood 
can be carried out with the fluid marrow, in- 
cluding total cell counts ; but the examina- 
tion of the stained film yields the most use- 
ful and important information. 

Marrow may also be obtained by remov- 
ing a small core of tissue by means of a 
trephine, and this method preserves the 
structural relationship of the cells. But it 
is technically more complicated, requires 
more time and manipulation for the prep- 
aration of microscopic sections and is not 
well adapted for repetition on the same pa- 
tient. It antedates the puncture method but 
is now seldom used for clinical diagnostic 
purposes. 

The use of marrow biopsy in clinical 
medicine is in its infancy, but already there 
are very definite indications for it. It may 
be expected to become more and more wide- 
ly used as detailed information of marrow 
changes in disease is accumulated. At 
present the diseases that present a specific 
marrow picture upon which a definite diag- 
nosis can be based are comparatively few ; 
but correlation with the clinical and pe- 
ripheral blood findings may be expected to 
increase its usefulness steadily. Among 
125 cases of various hematological disorders 
thoroughly studied by a recent investigator, 1 
the diagnosis was not settled by the usual 
means in twenty-six. Of these twenty-six 
cases marrow stud}' furnished a definite 
diagnosis in twenty, while the other six re- 
mained obscure. According to present 
knowledge there are three groups of dF- 

Tour. M.S.M.S. 


40 


BONE MARROW— STERN 


eases in which this procedure yields diag- 
nostic information. 

In severe anemia of the aplastic type, bor- 
derline cases occur in which questionable 
signs of regeneration may show in the blood 
and the diagnosis therefore remains in some 
doubt. Even though a cause for the anemia 
can be identified, as, for example, benzol, 
arsphenamine or excessive radiation, the 
question of possible recovery cannot be an- 
swered without knowledge of the state of 
the marrow. Failure of erythropoiesis some- 
times occurs late in the course of several 
of the major hematological disorders and 
requires recognition at least. In these cases 
extreme exhaustion of all cellular elements 
may be found in the marrow and definitely 
settles the diagnosis ; and since such a mar- 
row cannot be restored to any significant 
functional activity, the futility of such 
measures as transfusion is apparent. Some 
instances occur, however, in which the mar- 
row does not show what the circulating 
blood has indicated and may be merely 
hypoplastic or even normal. The difficulty 
lies in the altered threshold of cellular re- 
lease and is much less serious. It must be 
borne in mind that marrow puncture is a 
sampling process, and since the lesions may 
be patchy, there is the chance that the sam- 
ple is not representative. It is therefore in- 
advisable to base the diagnosis of marrow 
aplasia on only one biopsy. 

It may be mentioned in passing that in 
certain other anemic states marrow biopsy, 
while not of prime diagnostic importance, 
may furnish useful information. It is 
stated that true Addisonian anemia may be 
distinguished from carcinoma of the 
stomach with blood changes resembling per- 
nicious anemia through study of the mar- 
row. Of course, other and usually simpler 
means will accomplish the same purpose. 
Sub-acute combined degeneration of the 
spinal cord, of the type seen in pernicious 
anemia, may occur before any change in the 
blood is evident, and sternal puncture may 
offer an earlier means of making the diag- 
nosis in this very puzzling situation. Mala- 
rial parasites are said to be more numerous 
in marrow erythrocytes than in those in the 
blood stream. Culture of marrow fluid for 
the purpose of studying cell growth is at 
present an almost unexplored field, but one 
which offers great promise. 

The severe neutropenias with grave con- 

Tanuary, 1939 


stitutional symptoms, loosely called “agran- 
ulocytosis,” make up the second group of 
diseases in which marrow biopsy is of diag- 
nostic aid. In the fifteen years since this 
syndrome was described, many question- 
able cases have appeared in the literature, 
and much work concerning its possible 
causes has proved valueless because of lack 
of critical analysis of the clinical and 
pathological ‘findings. Marrow studies have 
helped to clarify our knowledge of these 
neutropenic states. It has been demon- 
strated that the peripheral neutropenia may 
or may not reflect the actual state of granu- 
lopoiesis, and that neutrophile formation 
may be normal, increased or decreased. The 
essential difficulty may thus relate to cell 
formation in some instances and to cell de- 
livery in others. In either event marrow 
biopsy is the only means for determining 
the fact. A certain number of cases of so- 
called agranulocytosis have proved to be in- 
stances of aleukemic leukemia or of aplastic 
anemia with equivocal blood findings; and 
while an accurate diagnosis in such cases 
has no effect on the outcome, it may avoid 
needless confusion and the encouraging of 
false hope for recovery. In other instances 
the finding of a normal marrow will enable 
the physician to proceed with confidence in 
a favorable result. 

The third group of diseases, and the one 
in which marrow biopsy at present shows 
its greatest diagnostic usefulness, includes 
some of the leukemias and closely related 
disorders. Typical leukemic changes in the 
peripheral blood are easily recognized and 
require no further investigation. But a con- 
siderable number of cases — more than is 
generally appreciated — do not show a diag- 
nostic blood picture ; and this is particularly 
true in the acute forms of the disease. Ref- 
erence is sometimes made to “atypical” leu- 
kemia in which the clinical or hematological 
findings do not correspond to the classical 
description, but this is misleading because 
all leukemias show typical anatomic lesions. 
It is not the disease but certain of its mani- 
festations which may be atypical, and it is 
in this type of case particularly that marrow 
biopsy is of diagnostic aid, for the leuko- 
blastic tissue practically alw T ays shows char- 
acteristic proliferation, regardless of the 
peripheral blood findings. In one large 
pathological service, 3 out of a total of fifty- 
six cases of leukemia, nine or 16 per cent 


41 


BONE MARROW— STERN 


were aleukemic and none of these nine was 
diagnosed clinically because the marrow was 
not examined during life. Acute or sub- 
acute aleukemic leukemia may simulate vari- 
ous diseases, notably aplastic anemia, 
thrombocytopenic purpura, pernicious ane- 
mia and sepsis, and treatment may be cor- 
respondingly misdirected. There are rare 
instances of leukemia in which the lesion 
is confined entirely to the marrow. The 
chronic aleukemic myeloid form has often 
been confused with Banti’s disease and 
splenectomy has been done. 

Lesions of the skin as a part of the leu- 
kemic process are fairly common, and when 
they occur in the course of known leukemia 
they offer no diagnostic difficulty. But in 
the absence of any other definite leukemic 
manifestations, as sometimes occurs, a very 
puzzling situation may arise. Dermatolo- 
gists 4 ’ 5 have written extensively about the 
diagnosis of leukemia cutis and lymph- 
oblastomas in general, in which group the 
nodular skin infiltrations in leukemia are 
classed. Clinically there may be a very close 
resemblance between the skin lesions seen in 
the various types of leukemia, Hodgkin’s 
disease, lymphosarcoma and mycosis fun- 
goides. Moreover, certain other cutaneous 
conditions such as exfoliative dermatitis, 
lupus erythematosus and dermatitis herpeti- 
formis seem to bear a definite although un- 
known relation to leukemia, and may be 
preceded or followed by it. Marrow biopsy 
is of considerable diagnostic aid in such 
situations when the peripheral blood find- 
ings are inconclusive. 

Clinicians have long been familiar with 
the leukemoid type of blood change which 
may occur particularly in response to infec- 


tion or malignancy. There may be mere- 
ly an unusually high leukocytosis in which 
case the resemblance to leukemia is slight. 
Or there may be many immature or abnor- 
mal cells in the blood which along with en- 
largement of the spleen or lymph glands, 
strongly suggest true leukemia. This dif- 
ferentiation has been extremely difficult at 
times, and often has had to rest on subse- 
quent developments. Marrow biopsy should 
aid greatly in making the proper diagnosis. 

Finally, it may be mentioned that tumors 
of the marrow, both primary and met- 
astatic, are occasionally found by biopsy. 
Since these lesions are always patchy, it is 
largely a matter of luck, however, if they 
are picked up in the aspirated material. 

Any medical inquiry into an illness be- 
gins, and ends, at the bedside. The clinician 
who anticipates a definite diagnosis in every 
case in which a biopsy is performed is 
doomed to disappointment, especially if the 
technical or laboratory details are handled 
by someone else. The hematologist himself 
is primarily a clinician, who studies the 
blood and its tissues of origin and brings to 
the bedside all the available data. 


Bibliography 

1. Dameshek, W. : Biopsy of the sternal marrow. Am. 
Jour. Med. Sci., 190:617, (Nov.) 1935. 

2. Doan, C. A.: The clinical implications of experimen- 

tal hematology. Medicine, 10:323, (Sept.) 1931. 

3. Jaffe, R. H.: The bone marrow. Jour. A.M.A., 107: 

124, (July 11) 1936. 

4. Keim, H. L. : The lymphoblastomas. Arch. Derm, and 

Syphilol., 19:533, (Apr.) 1929. 

5. Kingery, L. B., Osgood, E. E., and Illge, A. H.: 
Sternal puncture. Arch. Derm, and Syphilol., 35:910, 
(May) 1937. 

6. Peabody, F. W. : Hyperplasia of the bone marrow in 

man. Am. Jour. Path., 2:487, (Nov.) 1926. 

7. Sabin, F. R. : The bone marrow. Physiol. Rev., 8:191, 

(April) 1928. 

8. Young, R. H., and Osgood, E. E. : Sternal marrow 

aspirated during life. Arch. Int. Med., 55:186, (Feb.) 
1935. 


INTERPRETATION OF EXCESSIVE GONADOTROPIC HORMONES EXCRETED 
IN URINE IN EARLY PREGNANCY 

A. J. Kobak, Chicago ( Journal A.M.A., April 9, 1938), cites a case that demonstrates 
the difficulty in diagnosis when, after the expulsion of a hydatid mole, an unexpected preg- 
nancy intervenes. The diagnosis was obscured by the contraceptive precaution. Further- 
more, the possibility of a pregnancy occurring within four weeks from the date of the 
curettement was unlikely. With the uterus growing rapidly for one week, the hemorrhage 
and the hormone observations, the diagnosis of uterine pregnancy became even more 
dubious. The patient was admitted to the Michael Reese Hospital, where the uterus was 
emptied by an abdominal hysterotomy. It contained a normal fetus and placenta about 10 
weeks of age. The left ovary contained a normal corpus luteum of pregnancy. The 
fibroids were removed and the patient made an uneventful recovery. Microscopic exam- 
ination of the placenta showed nothing abnormal. Two subsequent Friedman tests were 
negative. When more negative reports are made, the diagnostic value of large quantities 
of gonadotropic hormones in the urine will be more limited. The clinical history and 
physical appearances should be given primary consideration before one concludes that 
chorionepithelioma or hydatidiform mole is present. 


42 


Tour. M.S.M.S. 


SOME REMARKS ON THE EXPERIMENTAL PSYCHOLOGY 
OF THE KRAEPELIN SCHOOL* 

EMIL AMBERG, M.D. 

DETROIT, MICHIGAN 


Kraepelin was a pupil of Wundt. Wundt stated that empirical natural science resents 
philosophical speculations which are not based on experience. 

He claimed that psychology should be based on philosophical premises but philo- 
sophical speculation shall only be recognized if it keeps in mind, at each step, the facts 
of psychologic experience as well as of experience of natural science. Plato liberated 
the soul from the body and opened the door to dualism. Aristotle softened the idea by 
carrying the soul as lifegiving and formative principle into matter. For him also the 


plant was a being with a soul. Descartes 
considered the soul exclusively a thinking 
being. Leibniz with his monad doctrine 
tried to replace the Cartesian soul substance 
by a more general principle, approaching 
again the conception of the Aristotalian 
soul. Herbart, so says Wundt, successfully 
refuted Wolff’s theory of the power of the 
soul with its superficial classification of proc- 
esses of the soul composed of memory, 
imagination, sensation, intellect, etc. Her- 
bart, however, wasted the best part of his 
perspicacity by inventing an entirely imag- 
inary system of mechanics of perception to 
which his metaphysical idea of the soul se- 
duced him. Descartes became the most 
powerful influence of that method of think- 
ing which led to modern materialism. If, 
so says Wundt, animals are natural auto- 
mata, in which everything occurs purely 
mechanically, which is generally considered 
perception, feeling, will, why should this 
proposition not hold good for man? The 
materialism of the 17th and 18th century 
drew this conclusion. There are a great 
number of experiences, which leave no 
doubt that there exists a connection between 
physiologic processes of the brain and 
psychic activities. May these few remarks 
by Wundt in the first lecture on the soul of 
man and animal (1892) suffice for an intro- 
duction of the subject matter, namely, 
“Some remarks on the experimental psy- 
chology of the Kraepelin School.” 

Kraepelin who died October 7, 1926, in 
his seventies, worked in Wundt’s labora- 
tory. On pages 358 and following, of 
Wundt’s Physiologic Psychology, 2nd vol- 
ume. 1893, Kraepelin’s work “The Influence 
of Some Drugs on Mental Efficiency, Jena 

*Read before the Detroit Philosophical Society, May 26, 
1938. 


1892,” is mentioned. It was a very im- 
portant contribution. Incidentally, I men- 
tion that space and time does not permit 
to dwell on the most important work of 
Fechner, Weber, Ebbinghaus, Cattell, Gal- 
ton and others. Kraepelin and his pupils 
have published their contributions from 
1896 until 1928, when the last number of 
“Psychologische Arbeiten,” Volume IX, part 
3 and 4, appeared. In the introduction of 
his first volume Kraepelin says: “When in 
the winter of 1879 a modest room was 
given to Wilhelm Wundt for psychologic 
experiments, he could scarely foresee the 
rapid advance of this new field of investi- 
gation. Fifteen years later pupils came 
from all over the world. Laboratories are 
now found in great numbers. Kraepelin en- 
titled his introduction “The Psychologic 
Experiment in Psychiatry,” but the investi- 
gations went far beyond it. The amount of 
work published is immense. August Hoch, 
M.D., has the following to say in his article 
“Kraepelin on Psychological Experimenta- 
tion in Psychiatry” ( American Journal of 
Insanity, January, 1896). 

“He not only applied methods which were used 
in experimental psychology, but devised new ones 
particularly fitted for the investigation of abnormal 
conditions ; and it is well to say at the beginning 
of the review that the objections which could be 
made to a study of this kind — namely, that experi- 
mental psychology is itself not enough advanced to 
be applied, so that it is questionable whether the 
methods there used are applicable to abnormal in- 
dividuals — do not hold good, since Kraepelin takes 
the methods less from physiologic psychology, than 
the experimental method in general.” 

Wevgandt (Psychologische Arbeiten), 
Volume IX, numbers 3 and 4, 1928, page 
371, states: 

“Yearly about 150 of our patients are examined 
psychologically. The forensically frequently very 

43. 


January, 1939 


EXPERIMENTAL PSYCHOLOGY— AMBERG 


important differential diagnosis between epilepsy and 
hysteria, between hypomaniac and other unrest, be- 
tween paralytic epileptic and schizophrenic and other 
feeblemindedness, between organic defects and com- 
pensation-hysterical disturbances, etc., find support- 
ing evidence in this manner, and not infrequently a 
decision. The investigations are supplemented by 
alcohol reactions with psychologic investigations. If, 
in a case, only a vague suspicion existed concerning 
hypomaniac traits, the association experiment pro- 
duced in more than 30 per cent reactions after the 
nature of word supplement, it entitles us to lean in 
court more strongly to the hypomaniac explanation 
and the deviation from logical orderly thinking.” 

The main factors which dominated some 
of the work of Kraepelin were the study of 
the influence of (a) practice, (b) fatigue, 
(c) the warming up effect, (d) the habit- 
forming which is lost very slowly in con- 
trast to the warming up effect, (e) impulse, 
which is of short duration, also the influence 
of the will at the end of work, and the end- 
spurt. These efforts fight against the influ- 
ence of fatigue (f) influence of disposition 
(good or bad disposition), (g) cooperation 
of influence of will and feeling, which is 
closely connected with the idea of coercion 
by imposed displeasing work in contradis- 
tinction to joy to work, (h) feeling of 
fatigue (psychopaths who break down by 
not noticing fatigue). We see that there 
are nine main factors at work. 

Methods 

Among the methods used by Kraepelin 
and his pupils, may be mentioned : 

1. Physical measures of time with the 
aid of Hipp’s chronoscope and the method 
of Cattell. The latter consists of visual im- 
pressions which appear before the eye with 
a certain measured velocity and are ob- 
served through a narrow slit. Objects may 
be letters, short or long words, sentences 
or illustrations. 

2. Measurement of associations. 

3. Fixation of association responses. 
The same associations appear after long in- 
termissions. 

4. The continuous methods of work first 
investigated by Oehrn, 1889, according to 
certain plans, (a) adding of single digits 
which consists in the reawakening of 
learned combinations of conceptions, (b) 
learning by heart of a series of twelve single 
digits or senseless syllables, as used first by 
Ebbinghaus. (Galton has examined that 
learning ability of mentally diseased chil- 
dren who could repeat only three to four 


letters at a time, whereas mentally healthy 
children could repeat seven and eight.) 

5. Reading. There is no method to 
measure the understanding but only the 
velocity with which a certain number of 
syllables are read (In this manner the na- 
tionality of a confidence man was estab- 
lished). Rieger has found many new facts 
in aphasic persons. 

6. Writing gives mainly an insight in 
purely peripheral phenomena. Grashey and 
Goldscheider had induced Kraepelin to con- 
struct a “writing scale.” 

7 . Measurements of the touch threshold 
(Griesbach). This is useful in following 
up fatigue. 

8. Time estimation with fatigue. The 
measured time spaces become gradually 
shortened. 

9. Examinations with the ergograph 
which allow to measure the work of certain 
muscles. Mosso had noticed that the work 
of the flexors of the hand was influenced 
by psychic influences. 

10. Measurements of the depth of sleep 
in the various timespaces after going to 
sleep (according to Kohlschuetter). 

Kraepelin admits that every endeavor to 
work out facts of experience by the mind 
can only be accomplished with the aid of 
imagination and therefore is apt to contain 
errors. 

Let me refer to “The Principles of 
Scientific Management” of Frederick Win- 
slow Taylor, Harper Brothers, 1911, and 
to the twelve principles of efficiency by Har- 
rington Emerson, N. Y. (The Engineering 
Magazine Company, 1916). 

If one considers the great amount of 
work which is done in this country in ex- 
perimental psychology, we are surprised at 
the variety of questions which are answered 
in the various laboratories. 

Kraepelin considered the “joy to work” 
as an essential point for national welfare. 
In our time, even in the United States, 
much consideration should be given to this 
factor. Kraepelin, in this manner, under- 
stood and emphasized the value of emotion 
many )^ears ago. 

He said in 1894: 

“It is highest time that also with us, in psychologic 
questions, the serious conscientious individual in- 
vestigation should replace ingenious statements and 
deep speculations. We do not get anywhere with 

Jour. M.S.M.S. 


44 


EXPERIMENTAL PSYCHOLOGY— AMBERG 


things which we cannot prove or contradict. We 
need facts, not theories. It is true that no science 
can do entirely without comprehensive views and 
temporary hypotheses, but we must never forget 
that these have no intrinsic value and that they 
cannot be recognized per se. They are nothing but 
means to an end. They are only justified when they 
ask definite questions and, thus, lead to new investi- 
gations. I think, says Kraepelin, that a sufficiently 
large number of questions have been asked. We 
shall now begin to answer them, not sitting at the 
desk, but in the laboratory, not by ingenious 
thoughts but by measurements and observation.” 

William James (The Thoughts and 
Character of William James by Perry, 
1938, p. 454) says: 

“Every cognitive project is on trial, and bound to 
submit itself to fresh findings of fact, no matter 
what other credentials it may possess. This in- 
cludes the judgment of science, common sense, re- 
ligion, and metaphysics. A philosophy is called em- 
piricism when same is contented to regard its most 
assured conclusions concerning matters of fact as 
hypotheses liable to modification in the course of 
future experience.” 

We must admit that the exact work of 
Kraepelin and his pupils has laid a founda- 
tion, the importance of which cannot be 
denied. Some may say that some of the re- 
sults could have been imagined without ex- 
perimentation. The very fact that the re- 
sults gave an explanation coinciding with 
actual experiences, shows how reliable ha\*e 
been the methods employed by Kraepelin 
and his pupils. Guess work has been re- 
placed by proven facts and exact measure- 
ments. 

Let me mention a few practical deduc- 
tions from the results of the investigations 


of the Kraepelin School, some in connection 
with other investigators. 

1. It is not right to place gymnastic exercises at 
the beginning of the school day, nor during the da)'. 
Gymnastic exercises belong at the end of the school 
day. Physical work tires the mind like mental work 
(Mosso, Bettmann). 

2. Overwork of pupils can be prevented if the 
more difficult subjects are not placed at hours of 
the school day when the pupil is tired. 

3. Intermission for rest must be longer at stated 
periods during the day. 

4. Sufficient sleep is an absolute necessity. 

5. The effects of exhaustive work can be traced 
for days and are not corrected by a one night’s 
rest (Bettmann). 

6. The strain of night work demands close at- 
tention. 

7. School work and housework demand close 
control by mental hygiene. Attention must be paid 
to the various mental capacities of pupils. 

8. The influence of alcohol and other drugs must 
be considered ( Aschaffenburg and others). 

9. The high pressure methods must be recognized 
in their damaging influences. (Incidentally, may I 
remark that nature cannot be deceived. We know 
that some people in their appearance, actions and 
health have used, or, better, abused, their physical 
inheritance so that their bodies are used up long be- 
fore they should have been). 

10. Like the thermometer is used to measure the 
body temperatures, the stethescope to investigate the 
conditions of organs in the body, the medical labora- 
tory to find changed conditions in bodily health, so 
do the investigations in psychophysical laboratories 
look into the rules which govern mental activities 
(Weygandt, etc.). 

11. The work and evaluation of experimental 
psychology are only beginning to be recognized in 
their true value and in their importance for a 
healthy life of the individual and of the human race. 

12. This work engages the efforts of trained ob- 
servers and skilled interpreters, so that pitfalls may 
be avoided as much as possible. 


THE BRAIN 

(From Dr. Oliver Wendell Holmes’ “Living Temple”) 

Then mark the cloven sphere that holds 
All thought in its mysterious folds. 

That feels sensation’s faintest thrill, 

And flashes forth the sovereign will ; 

Think of the stormy world that dwells 
Locked in its dim and clustering cells. 

The lightening gleams of power it sheds 
Along its hollow, glassy threads. 

O, Father, grant thy love divine 
To make these mystic temples thine. 

When wasting age and wearying strife 
Have sapped the leaning walls of life, 

When darkness gathers over all, 

And the last tottering pillars fall, 

Take the poor dust thy mercy warms, 

And mould it into heavenly forms. 


January, 1939 


45 


SUBMAXILLARY STONES 


Case Report 


JAMES B. BLASHILL, M.D. 

DETROIT, MICHIGAN 


A brief review of the literature shows that in some regions more parotid stones than 
submaxillary are found. In other geographical regions the exact opposite is true. The 
composition of the stones is almost identical with tartar which collects on the teeth. 
Both swarm with micro-organisms. The etiology is as indefinite as is that of stones 
found elsewhere. The size of the stones varies from that of a millet seed to one over 
an inch in length. Each submaxillary gland, composed of around 1,500 lobules, is 
drained by Wharton’s duct, the external orifice of which is found just behind the lower 


incisor teeth in the floor of the mouth. The 
ejection of saliva within the gland is accom- 
plished by the secreted saliva within the 
gland which has been found to be greater 
than the arterial blood pressure when it is 
in full activity. 

Submaxillary stones are found three 
times more often in males than in females. 
They may produce no symptoms and are 
discovered accidentally through x-ray exam- 
ination. In most cases, pain is quite pro- 
nounced and occurs at the beginning of a 
meal. Another common finding is swelling, 
which occurs as soon as eating is begun. 
The swelling is located on either side, be- 
neath the mandible, but if very great, may 
extend above. At times, a swelling is found 
in the floor of the mouth. Usually relief 
is sought because of secondary infection 
which has aggravated existing symptoms. 

Examination often discloses saliva com- 
ing only from the unaffected side. At 
times the stone can be seen just behind the 
orifice of Wharton’s duct as a yellowish 
object. If pressure is applied to the swell- 
ing, the duct balloons out. This same pro- 
cedure may push the stone through the ori- 
fice. A great spurt of saliva follows. 

The purpose of reporting this case is to 
call attention, to the number of stones that 
have been recurring. The literature on 
submaxillary stones is very extensive but 
little is said about the same patient return- 
ing with more stones. Ivy and Curtis 2 had 


one patient return after two years with a 
single stone on the same side, and another 
patient returned after two and one-half 
years with a single stone on the opposite 
side. 

Case report of Mr. L. R., aged fifty-eight. Sub- 
maxillary stones have been removed from Whar- 
ton’s duct exactly eight times since October 29, 
1933. Stones were removed from the right side 
three times and from the left .side five times. They 
were extracted from the duct by exerting pressure 
on the swelling and either dilating or incising the 
duct orifice. At times the stones could be seen 
through the orifice, at other times they were located 
further back. In all recurrences only one stone was 
found. All of the stones were very friable, crush- 
ing with slight pressure. The largest was only 0.5 
cm. They varied considerably in shape, being cylin- 
drical, round, ovoid, et cetera. The recurrence at 
times was very rapid. The first stone to be re- 
moved was on October 29, 1933, right side. Then, 
less than two months elapsed when the second one 
was taken from the left side on December 18, 1933. 
Nearly a year later, October 13, 1934, one was re- 
moved again from the left side. On April 23, 1935, 
a stone was removed from the right side. Twenty- 
two months later, on June 14, 1937, another stone 
was found on the right side. The last three have all 
been from the left side. They were removed on 
the following dates: December 28, 1937, January 5, 
1938, and September 19, 1938. The only symptoms 
of which this patient complains is that of swelling. 
Each time it has occurred at the beginning of a 
meal. 

Bibliography 

1. Bailey, H.: Branchial Cysts, pp. 52-73. 

2. Ivy, R. H., and Curtis, L. : Salivary calculi. Ann. 

Surg., 96:979-986, 1932. 

3. Ivy, R. H., and Curtis, L. : Salivary calculi. Internat. 

Jour. Orthodontia, 22:179-182, (February) 1936. 


46 


Jour. M.S.M.S. 


POSTERIOR VAGINAL ENTEROCELE* 

Report of Two Cases 

EARL G. KRIEG, M.D. 

DETROIT, MICHIGAN 

The report and the discussion of the two cases presented here is to point out that ex- 
ceedingly small series of cases of enterocele are still being reported and secondly to 
record a case that presents a complication not hitherto found in the literature. 

Case 1 presents a posterior vaginal enterocele complicated by an acute intestinal ob- 
struction and is as follows: 


Case 1. — Mrs. — , a white woman, aged thirty 
years, was admitted to the hospital with symptoms 
of acute intestinal obstruction, May 31, 1936. She 
had been seized with a pain in the left pelvic region 
which was so severe that she fainted. When she 
returned to consciousness .she had recurrent lower 
abdominal cramps and some nausea, and a feeling 
of pressure in the vagina. 

Six weeks previously she began to have severe 
crampy pains in the lower left quadrant that came 
on suddenly. Since then at irregular intervals the 
pains returned and were often associated with heavy 
work. These pains would last for a few minutes 
to one-half hour and were accompanied by nausea, 
vomiting and a distinct sense of pressure in the 
pelvis. Decubitus relieved the attacks until the 
present illness. 

Her past history was of no interest except that 
she had delivered two children and the- first had 
been a long, hard labor. 

Physical examination revealed the following perti- 
nent findings. There was slight pain on deep pres- 
sure in the lower left quadrant. The genitalia re- 
vealed old lacerations of the perineal muscles. The 
cervix was pushed behind the symphysis by a fixed 
cystic mass in the posterior vaginal vault. The 
mass measured approximately 9 cm. in diameter and 
extended downward to the levator muscles. The 
mass could not be reduced by pressure through the 
vagina but when digital pressure was applied 
through the rectum the mass was reduced and the 
intestinal colic stopped ; this maneuver had all of 
the characteristics attributed to the manual reduc- 
tion of an incarcerated inguinal hernia. 

Operation was performed, using the technic de- 
scribed by George Gray Ward. The sac was dis- 
sected free as high as the utero-sacral ligaments 
and tied off. The utero-sacral ligaments were 
sutured together as far as the rectum and the her- 
nial opening was closed, using interrupted silk. 
Levatorrhaphy was done. 

Convalescence was uneventful and she has had no 
recurrence. 

Case 2 presents uterine prolapse with 
cystocele, rectocele and posterior enterocele. 

Case 2. — Mrs. E. S., white, aged thirty-nine years, 
complained of a sense of pelvic pressure and weak- 
ness, backache and vaginal discharge. These symp- 
toms began with the first delivery about 16 years 
ago and became worse with each of the four suc- 
ceeding pregnancies. During the last six weeks she 
has had intermittent vaginal bleeding. 

Examination revealed an obese woman with no 
pertinent findings except those referable to the 
pelvis. 


*Frorn the Department of Gynecology, Receiving Hospital 
and Wayne University College of Medicine. 

January, 1939 


Pelvic examination revealed a marked laceration 
of the perineal muscles ; the uterus was slightly 
larger than normal and dropped downward as far 
as the levator muscles. There was a severe lacera- 
tion of the cervix with edema and redness ; there 
was a large cystocele and rectocele, the latter ex- 
tended upward to the posterior fornix. 

Operation was performed August 20, 1936. A 
vaginal hysterectomy was done, using the Mayo 
technic for the repair ; silk was used to fix the broad 
ligaments to the symphysis pubis on either side. 
During operation the enterocele was demonstrated 
to make up about one-half of the “rectocele” mass 
and it was repaired with silk, using the technic of 
George Gray Ward. The patient has had no further 
trouble. 

Discussion 

Posterior vaginal hernia or enterocele, 
electrocele, hernia of the cul-de-sac of 
Douglas and high rectocele are the more 
common terms used in the literature to des- 
ignate a herniation that extends through the 
cul-de-sac into the area between the rectum 
and vagina. Enteroceles are frequently un- 
recognized or are mistaken for rectocele. 
The successful repair of enterocele differs 
from that of rectocele because of the anat- 
omy involved. Enterocele is not frequently 
reported and only in the last six years have 
standard textbooks described the condition. 
Bueerman in 1932 found only 81 cases dur- 
ing an exhaustive search of the literature; 
he added three cases. Masson reported 
eleven new cases in the same year and since 
then to October, 1938, nine additional cases 
are mentioned. Since Garengoet reported 
the first case in 1736, the total number is 
eighty-seven cases. Without doubt the in- 
cidence of enterocele is far above this figure. 

Etiology 

A congenital defect in the structural de- 
velopment of the parts is the primary etio- 
logical factor. Zuckerkandl, Moschcowitz, 
Jones and others have shown that a deep 
cul-de-sac is always found with enterocele. 
The secondary factor is trauma which is 
initiated by parturition in 90 per cent of the 


47 


POSTERIOR VAGINAL ENTEROCELE— KRIEG 


cases. Operation, contusion and intra- 
abdominal pressure brought on by severe 
exertion, ascites, tumor, etc., are the less 
frequent causes. 



Posterior enterocele is only one of a 
group of hernise that project into the vag- 
inal canal or at its orifice. (See drawings.) 
Herniae about the vagina may be divided 
into two groups, the common and the un- 
common varieties. Cystocele and rectocele 
comprise the first group and need no discus- 
sion here. 

In the second group there are four varie- 
ties: 

1. Posterior enterocele comprises 74 per 
cent of the cases, according to Bueerman. 
This hernia may project downward as far 
as the levator muscles. 

2. Anterior enterocele projects through 
the anterior cul-de-sac between the bladder 
and the uterus and comprises 20 per cent 
of these cases. 

3. Pudental herniae project through the 
broad ligament just lateral to the uterus and 
appear in the lateral wall of the vagina or 
pudenda. 

4. Ischio-rectal herniae project through 
the levator muscle near the “white line” 
and appear lateral to the rectum ; they are 
quite rare. 

Symptoms of enterocele are not charac- 
teristic and are similar to those related to 
rectocele. The gradual appearance of a 
mass, the associated pressure upon neigh- 
boring organs and various degrees of local 


discomfort are the usual signs. In about 
one-third of the cases the onset is sudden 
and in three cases reported signs of intes- 
tinal obstruction appear. The prone posi- 



ISCHIORECTAL HERNIA PUDENTAL HERNIA 


Fig. 2 

tion may relieve all symptoms. The recur- 
rence of a mass following a perineal repair 
or a hysterectomy is very suggestive. 

Diagnosis is best established by reducing 
the hernia by rectal approach and prevent- 
ing its return by pressure of the finger 
against the neck of the sac at the cervix. 
In large enteroceles peristalsis may be seen. 

The indications for repair are as follows: 

1. Active symptoms similar to those 
found in pelvic prolapse. 

2. Steady increase in size of the hernia. 

3. Signs of intestinal incarceration. 

4. Discovery of the condition during the 
repair of perineal lacerations or uterine 
prolapse. 

5. For prophylaxis against such reported 
complications as interference with parturi- 
tion, rupture of the hernia with evisceration 
and injury to the bowel due to faulty diag- 
nosis. 

In about 46 per cent of Bueerman’s series 
no operation was done and in seven cases 
(11.8 per cent) the condition disappeared 
spontaneously following delivery or pelvic 
infection. 

Treatment of enterocele is surgical and 
one of two methods is chosen. The Mosch- 
cowitz technic closes the cul-de-sac by the 
abdominal route by using a series of super- 
imposed purse-string sutures of silk oi- 
lmen. 

The Ward technic employs the vaginal 

Jour. M.S.M.S. 


48 


QUINIDINE SULPHATE THERAPY— HAMMONDS 


approach and removes the sac as high as 
the uterosacral ligaments, which are sutured 
together as far as the rectum, and then the 
canal is closed by interrupted sutures. Un- 
less there is complicating pathology that 
cannot be approached through the cul-de- 
sac, I believe that the latter technic is to 
be preferred, not only by the surgeon but 
also for the benefit of the patient. 


Bibliography 


1. Bueerman, W. H- : Vaginal enterocele. Jour. A.M.A., 

99:1138-1143, (Oct. 1) 1932. 

2. Jones, D. F. : Relation of deep cul-de-sac to prolapse 

of rectum and vagina. Bost. Med. & Surg. Jour., p. 
632, (Nov. 2) 1916. 

3. Masson, J. C. : Prolapse, cystocele, rectocele and true 

vaginal hernia. Jour. A.M.A., 99:1143-1146, (Oct. 1) 
1932. 

4. Moschcowitz, A. V. : Perineal hernia. Surg., Gyn. and 

Obst., 26:514, 1918. 

5. Ward, G. S. : Enterocele. Jour. So. Med. Assn., 79: 

709, 1922. 

6. Zuckerkandl: Quoted by Bueerman. 


A RESUME OF QUINIDINE SULPHATE THERAPY 
E. E. HAMMONDS, M.D. 

BIRMINGHAM, MICHIGAN 

Quinidine was brought to the attention of the medical fraternity twenty years ago. 
Its earlier champions 7 ’ 12 held forth brilliant possibilities for the drug in the treatment of 
irregularities of the heart beat. Later clinicians 4 ’ 10 ’ 15 have used the drug with increas- 
ing respect, both for its therapeutic value and for its irregular toxic effects. Although 
quinidine is not the panacea for irregularities that we had first hoped it might be, it has 
become a definite aid to us in the control of certain factors in heart disease and has 
added another rung to the ladder of knowledge of heart physiology. 


Quinidine sulphate is derived from cin- 
chona and is the dextroisomer of quinine. 3 
Quinidine is less of a protoplasmic poison 
than quinine and is less effective in the 
treatment of malaria. 

Quinidine sulphate exerts its action by in- 
creasing the refractory phase of contracting 
heart muscle. 6 It is said 6 to have the abil- 
ity to depress the property of irritability of 
heart muscle, but the term “depressed irri- 
tability” does not seem proper in light of the 
physiology of cardiac muscle. By lengthen- 
ing the refractory phase of myocardium it 
causes extra-nodal foci of excitation to fall 
upon the heart muscle when it can not re- 
spond to stimuli other than those coming 
over the conducting system at the proper 
interval. Fortunately quinidine has little or 
no effect upon the sinus node and by the 
same token should not be used to correct a 
sinus tachycardia. It has little or no effect 
upon the tone of heart muscle. 

Its more common toxic manifestations, 5 ’ 17 
which are in the vast majority of cases due 
to excessive doses, are tinnitis, nausea, 
vomiting, headache, diarrhea, skin rashes, 
and, rarely, sudden death. 

Because of the antagonistic action of 
digitalis and quinidine they are often used 
in conjunction with one another, but there 
is no logical reason for this. It has been 
shown 0 ’ 13 that while quinidine will prevent 
some of the toxic arrhythmias produced by 

January, 1939 


digitalis, when both drugs are used together 
there are electrocardiographic changes pro- 
duced which are not found when either 
drug is used alone. There should be little 
objection to slowing the rate of fibrillation, 
in some cases, with digitalis prior to the ad- 
ministration of quinidine, providing the pa- 
tient has not been over-digitalized. 

Digitalis definitely increases tone and con- 
tracting ability of heart muscle and also in- 
creases the conduction time over the bundle 
of His. Quinidine has little or no effect 
on these phenomena. 17 

Quinidine is indicated in cases of par- 
oxysmal auricular fibrillation, both to stop 
the attacks and lessen the frequency of their 
occurrence. 11 ’ 12 ’ 13 The optimum dose is 
twelve to forty grains a day for not more 
than seven or eight days, following a sensi- 
tizing dose. In uncomplicated cases we are 
led to believe that we may expect a return 
to normal rhythm in about 50 per cent of 
trials. It is agreed 4 ’ 5 ’ 11 ’ 15 that the best re- 
sults are obtained in patients who have not 
been fibrillating more than a few months, 
who have no evidence of decompensation or 
heart failure, who have no sign of cardiac 
pathology, and who have not had embolic 
phenomena. 

There has been a great difference in opin- 
ion regarding the dangers of quinidine in 
cases of established fibrillation. The two 


49 


QUINIDINE SULPHATE THERAPY— HAMMONDS 


principal hazards are syncope and embolism 
due to dislodging of a clot from the auricles. 
Fatalities due to quinidine are rare but a 
number of sudden deaths have been re- 
ported from reliable sources. 17 In cases of 
long standing fibrillation it seems question- 
able whether the benefit of temporary re- 
turn to sinus rhythm justifies the exposure 
of the patient to the large doses usually re- 
quired. 

It is generally agreed 1 ’ 5 that it is unsafe 
to administer quinidine to thyrotoxic pa- 
tients sooner than ten days following 
thyroidectomy, because thyroxin is stored 
in excessive amounts in the myocardium up 
to that time at least and this makes the 
action of quinidine uncertain. 

Quinidine should be tried in cases of 
auricular flutter. 8,9,11 While digitalis is still 
held as the more effective remedy by some, 
the attacks may be lessened in frequency 
and in duration in most cases by not more 
than nine grains a day for four to six days. 

Paroxysmal tachycardias of both auric- 
ular and ventricular types are definitely 
benefited by the use of quinidine. 11 

There is less general agreement as to the 
beneficial effects of quinidine in the cases of 
extrasystoles. The most logical argument 
in favor of quinidine is that it tends to 
lessen the probability of a more serious 
arrhythmia. 14 Bohan 5 reports the successful 
use of quinidine in ambulatory cases by the 
administration of six to nine grains a day 
for four days followed by a rest period of 
three days before repetition. 

Quinidine is becoming increasingly im- 
portant as a therapeutic agent in the treat- 
ment of myocardial infarction. 5,11,16 The 
cause of death in these cases is usually 
fibrillation of the ventricles. Many writers 
advocate the use of five grains four times a 
day from two to six weeks to prevent any 
fatal arrhythmia during the recovery period. 
Quinidine should also be given in cases of 
angina pectoris when attacks are frequent, 
not to stop pain, but to prevent ventricular 
fibrillation. 8 ’ 11 


In conclusion: 

1. Quinidine is of definite value in the 
therapy of uncomplicated paroxysmal auric- 
ular fibrillation and in paroxysmal tachy- 
cardias of both auricular and ventricular 
types. 

2. It may be of value in cases of long 
standing auricular fibrillation and of auric- 
ular flutter, and in the therapy of extra- 
systoles. 

3. It may be of value in cases of myo- 
cardial infarction and angina pectoris by 
preventing the occurrence of a fatal arrhy- 
thmia. 

4. It will not correct a sinus tachy- 
cardia. 


Bibliography 


1. Anderson, J. P. : Quinidine therapy in the treatment 

of cardiac irregularities due to hyperthyroidism. Ann. 
Int. Med., 5:825-828, (January) 1932. 

2. Arjeff, M.: Quindine in auricular fibrillation. Deutsche 

Med. Wchnschr., 49:576-577, 1923. 

3. Barr, David Preswick: Necessary Drugs and the 

Knowledge Essential to Their Use. 1932. 

4. Berthea, O. W. : Digitalis and quinidine: Their clin- 

ical use. Int. Med. Digest, 23:243-249, (October) 1933. 

5. Bohan, Peter T. : Quinidine sulphate: Its actions and 

uses. Jour. Missouri State Med. Assoc., 32:353, (Sep- 
tember) 1935. 

6. Boyer, Paul: Experimental cardiovascular action of 

quinine and quinidine. Jour. Med. frqnc., 17:223-227, 
1928. 

7. Clerc, A., and Pezzi: Action of quinidine on auricular 

fibrillation. Paris Med., 11:440-445, (December) 1921. 

8. Gold, L. O., Otto, H. L., and Satchwell, H. : The use 

of quinidine in ambulatory patients for the prevention 
of paroxysms of auricular flutter. Amer. Heart Jour., 
9:219, (December) 1933. 

9. Jezer, Abraham, and Schwartz, Sidney P. : Unusual 

manifestations following the use of quinidine in a 
patient with auricular flutter. Amer. Heart Tour., 
10:124, (October) 1934. 

10. Kohen, Cecil M., and Levine, Samuel A.: An evalua- 

tion of the use of quinidine sulphate in persistent auric- 
ular fibrillation. Ann. Int. Med., 8:923, (February) 
1935. 

11. Levine, Samuel A.: Clinical Heart Disease. Philadel- 

phia, W. B. Saunders Co., 1936. 

12. Lian, C. : Quinidine sulphate in the treatment of com- 

plete arrhythmia. Jour, de Med. et Chir. Prat., 43:505, 
516, 1922. 

13. Maher, C. C., Sullivan, C. P., and Scheribel, C. P. : 

Effects on electrocardiograms of patients with regular 
sinus mechanism of quinidine. Amer. Jour. Med. Sci., 
187:23, (January) 1934. 

14. McQuine, Johnson: Extrasytoles and their treatment 

with quinidine sulphate. Ohio State Med. Jour., 28:260, 
(April) 1932. 

15. Newman, William W., and Spiro, H. : Quinidine 

therapy in auricular fibrillation: An evaluation based on 
its use over a six-year period. Calif, and West. Med., 
37:19-25, (July) 1932. 

16. Norawitz, P. : Quinidine as a prophylactic of acute 

heart failure. Verhandl. d. deutsch. Gessellsch. f. inn. 
Med., 41:351, (April) 1932. 

17. Van Wely, H. : Influence of quinidine on the conduc- 

tion system. Nederlandsch. tijdschrift voor geneeskunde, 
71:1651, 1927. 



50 


Jour. M.S.M.S. 


EDITORIAL 


THE JOURNAL 

OF THE 

Michigan State Medical Society 


PUBLICATION COMMITTEE 


A. S. BRUNK, M.D., Chairman Detroit 

F. T. ANDREWS, M.D Kalamazoo 

T. F. HEAVENRICH, M.D Port Huron 

ROY H. HOLMES, M.D Muskegon 

J. EARL McINTYRE, M.D Lansing 


Editor 

J. H. DEMPSTER, M.A., M.D. 
5761 Stanton Avenue, Detroit, Michigan 


Secretary and Business Manager of The Journal 
L. FERNALD FOSTER, M.D. 

Bay City, Michigan 


Executive Secretary 
WM. J. BURNS, LL.B. 

2642 University Avenue, St. Paul, Minnesota 
or 

2020 Olds Tower, Lansing, Michigan 


JANUARY, 1939 

" Every man owes some of his time to the up- 
building of the profession to which he belongs ” 

— T heodore Roosevelt. 


EDITORIAL 

CUT RATE PHYSICAL 
EXAMINATIONS 

A new federal law makes it mandatory 
that all truck drivers engaged in interstate 
commerce submit to and pass satisfactorily 
physical examinations. These are presum- 
ably to be the responsibility of the employer, 
to be paid for by him. A new agency has 
been organized to assist the employer by 
providing him with the necessary forms, 
data and advice required by the new law. 
There is no particular objection to this. We 
understand, however, that while, as men- 
tioned, the selection of the doctor and pay- 
ment for his services is the function of the 
employer, the service organization men- 
tioned is in a position to recommend phy- 
sicians and actually does this. Further- 
more. that physical examinations are actual- 

January, 1939 


ly being made for a dollar each and some- 
times for less. The physical examination 
blank has been examined by the medical 
economics commission of the Wayne County 
Medical Society, who maintain that a proper 
filling out of the form requires as much 
time and care as entailed in an ordinary life 
insurance examination. 

How an experienced professional man 
can make these examinations for a dollar is 
difficult to comprehend. As charity, he 
often gives his sendees, but this is not a 
matter of charity. The truck driver may 
require a passport photo as a means of iden- 
tification. All taxi drivers do. If so, he 
will pay at least a dollar for his photo by 
a photographer whose skill and training and 
responsibility do not compare with that of 
the doctor. 

The physical examinations are for the 
sake of greater safety on the highways. 
Why then should not the matter be taken 
seriously? Why enter into any agreement 
the proper carrying out of which is apt to 
lead to cheap and slipshod work? If the 
laborer is worthy of his hire, why is not the 
physician also? The term “cut rate,” 
wherever one encounters it, leads to the sus- 
picion of inferiority. After all, one usually 
gets what he pays for, sometimes less, sel- 
dom more. The federal law requiring the 
physical examination of truck drivers was 
enacted for the purpose mentioned. Why 
render it useless by treating it as if it were 
an unimportant piece of legislation that may 
be dispensed with in the most routine way? 


THE LAY PRESS 

The November number of Fortune con- 
tained an article on the American Medical 
Association ; and, by the way, let each 
reader of the Journal of the Michigan 
State Medical Society not lose sight of the 
fact that this refers to him as a member 
of the great body of organized medicine in 
the United States. The article in Fortune 
is based upon “three months of research,” 
the conclusion of which is that “the Amer- 
ican Medical Association has worked 
against its own purposes by changing to 
ideas that have been discredited. Today it 
finds itself within hailing distance of its 
own downfall and it is now in a process 
of acknowledging defeat of its leadership.” 

Some wise person has said that the apple 
tree with the finest fruit is that which has 


51 


EDITORIAL 


the most clubs lying on the ground around 
it. If there is any truth in this, the medical 
profession can certainly take heart over the 
attention it has received in the past few 
years. 

Prior to the appearance of the Novem- 
ber number of Fortune, many physicians 
throughout the United States, including the 
editor of this Journal, received letters 
drawing attention to the forthcoming article 
on the medical profession. Dr. Andrew P. 
Biddle, who is one of the best known men 
in Michigan medicine, has written a reply 
to said letter after reading the article in 
Fortune. Dr. Biddle’s letter is very much 
to the point. He speaks from an experi- 
ence of over half a century, which surely is 
entitled to a hearing as compared with 
“three months’ research.” Dr. Biddle em- 
phasizes the personal relationship between 
patient and physician, and goes on to 
say that the analogy often made between 
medical service in the army and medical 
service to the lay population is beside the 
point, owing to the fact that both soldier 
and sailor and medical staffs of the army 
and navy are under military and often war- 
time discipline. In reply to the statement 
that the medical profession had not yet 
removed the preponderance of many dis- 
eases, among them syphilis, Dr. Biddle 
makes the emphatic statement that “there 
is no comparison in what constituted care 
of syphilis at the time of my graduation in 
1886 and what it is today. The case is as 
different as night and day.” Everyone 
would agree to this even though his ex- 
perience may not have gone back farther 
than two decades. 

Dr. Biddle deplores the attitude of many 
younger physicians “who grasp at a fancied 
economic security and sell their soul for a 
temporary appeasement.” There are rea- 
sons for this which we will not discuss. 

Dr. Biddle makes a strong point in the 
following paragraph: 

“In reply to your letter I cannot understand why 
you editors would inflict upon others socialized medi- 
cine, governed by bureaucratic politicians, w'ho know 
nothing of medicine and the sick and care less, 
that which you would not impose upon and sub- 
mit to yourself. You are insistent upon the free- 
dom of the press. Why deny us freedom of 
thought and action?” 

Yes, why are some editors so insistent on 
maintaining the guarantee of the constitu- 
tion regarding the freedom of the press and 

52 


at the same time evince a willingness to im- 
pose regimentation on the medical profes- 
sion? We hesitate, however, to indict the 
entire press, for the simple fact that a large 
number of editors do champion that free- 
dom for others that they insist upon for 
themselves. 

Dr. Biddle goes on to say “there are con- 
ditions which effect the general public and 
which cannot be handled except through 
public agencies; but these conditions do not 
usually apply to the individual.” Every 
rational person will concede this. 

The reader is reminded that medical 
ethics, which has come in for so much 
obloquy, has come down through the cent- 
uries to define a working behavior towards 
the patient, towards the public and among 
doctors themseh’es and has, therefore, a 
survival value. Dr. Biddle goes on to say 
that “some of its principles are fundamental 
and eternal. Others are liquid and are 
changed from time to time to meet the 
changing conditions of human relations. In 
conclusion, the doctor wisely maintains that 
“we shall not submit to mass regimentation 
so long as we have to force to endure.” 


A NEW CIRCUMCISION TECHNIC 

In an attempt to simplify the operation of cir- 
cumcision an instrument consisting of two parts is 
used. The first is a spindle-like part having bell- 
shaped ends of a large and a small size. Around 
each end is a groove into which the wire ring of 
the second part contracts. The spindle is hollow, 



to prevent a vacuum attaching the instrument to 
the glans, and to permit escape of urine in case a 
baby should void during the operation. The second 
part is like a hemostat with curved beaks into which 
is fitted a wire ring which expands and contracts 
as the instrument is opened and closed. As the 
beaks open, the wire ring opens on one side to 
permit it to be slipped onto the spindle from the 
side rather than over the end. 

In changing the instrument to a different size the 
opposite end of the spindle is used and the wire 
ring is replaced by one of the other size, a procedure 
which is as quick and easy as changing the wire 
in a tonsil snare. However, unless it is necessary 
to change sizes, the same wire does for an in- 
definite number of circumcisions. The smaller size 

Jour. M.S.M.S. 


EDITORIAL 


is suitable for boys from birth to six or seven 
years of age, and the larger size for older males. 

The circumcision is performed by making a dorsal 
slit and freeing the adhesions between the prepuce 
and the glans. The prepuce is then stretched over 
the bell-shaped end of the spindle and held in place 
by the thumb and index finger of the left hand while 
the wire ring clamp is slipped onto the spindle at 
the level of the groove with the other hand. The 
wire ring is then contracted, crushing the prepuce 
into the groove. The instrument is left in place 
about ten minutes, after which the prepuce is trim- 
med off close above the wire with a scalpel and 
the instrument removed. Usually no suturing is 
required and no bleeding occurs. 

The advantages of the technic are : it facilitates 
the operation, it saves suture material, and the 
completed operation is smoother. 

E. M. Smith, M.D. 

16 Monroe Ave., 
Grand Rapids, Mich. 


WHO IS LIABLE FOR TAX 

Operators of private laboratories, private sani- 
tariums, and physicians employing one or more 
were advised today by Commissioner of Internal 
Revenue Guy T. Helvering to make immediate tax 
returns as required under the provisions of Titles 
VIII and IX of the Social Security Act to avoid 
further payment of drastic penalties which are now 
accruing. 

Commissioner Helvering pointed out that every 
person involved in such work came under the 
provisions of Title VIII, which imposes an income 
tax on the wages of every taxable individual and 
an excise tax on the pay roll of every employer 
of one or more. This tax is payable monthly at 
the office of the Collector of Internal Revenue. 
The present rate for employer and employe alike is 
one per cent of the taxable wages paid and re- 
ceived. 

Under Title IX of the Act, employers of eight 
or more persons must pay an excise tax on their 
■annual pay roll. This tax went into effect on Janu- 
ary 1, 1936, and tax payments were due from the 
employers, and the employers alone, at the office 
of the Collector of Internal Revenue on the first 
of this year. This tax is payable annually, although 
the employer may elect to pay it in regular quarterly 
installments. 

The employer is held responsible for the collec- 
tion of his employe’s tax under Title VIII, the 
Commissioner explained, and is required to collect 
it when the wages are paid the employe, whether it 
be weekly or semi-monthly. Once the employer 
makes the one per cent deduction from the em- 
ploye’s pa}', he becomes the custodian of Federal 
funds and must account for them to the Bureau 
■of Internal Revenue. 

This is -done, Mr. Helvering said, when the em- 
ployer makes out Treasury form SS-1, which, ac- 
companied by the employe-employer tax, is filed dur- 
ing the month directly following the month in which 
the taxes were collected. All tax payments must 
be made at the office of the Collector of Internal 
Revenue in the district in which the employer’s 
place of business is located. 

Penalties for delinquencies are levied against the 
employer, not the employe, the Commissioner point- 
ed out, and range from 5 per cent to 25 per cent 
of the tax due, depending on the period of delin- 
quency. Criminal action may be taken against those 
who wilfully refuse to pay their taxes. 

The employers of one or more are also required 
to file Treasury forms SS-2 and SS-2a. Both are 
informational forms and must be filed at Collectors’ 

January, 1939 


offices not later than next July 31, covering the 
first six months of the year. After that they are 
to be filed at regular quarterly intervals. Form 
SS-2 will show all the taxable wages paid to all 
employes and SS-2a the taxable wages paid each 
employe. 


AMERICAN MEDICO-LEGAL 
ASSOCIATION 

We have received Number I, Volume I, of the 
American Journal of Medical Jurisprudence, the 
official organ of the American Medico-Legal Asso- 
ciation, with offices at 137 Newberry Street, Boston, 
Massachusetts. Dr. Frederick C. Warnshuis, for- 
merly secretary of the Michigan State Medical So- 
ciety, is the editor. Dr. Warnshuis is also president 
of the American Medico-Legal Association. The 
journal is unique in its appeal to the professions of 
Medicine, Law and Dentistry. The editorial board 
comprises nineteen of the most outstanding authori- 
ties on medical jurisprudence in the United States. 
The journal consists of seventy-two double column 
pages of reading matter in good, clear type. The 
purposes and scope of the work of the new associa- 
tion are as follows : 

(a) To edit and publish the American Journal of 
Medical Jurisprudence ; 

(b) To assume leadership in the conducting of an 
educational movement directed to bring dependable 
information to physicians, dentists, hospitals, attor- 
neys, employers and employes upon questions relating 
to the legal provisions governing the rendering of 
professional services ; 

(c) To inaugurate movements, to mold sound 
opinions and to establish unity of standards and ac- 
tion in medico-legal relationships ; 

(d) To devise ways and means to inspire and 
encourage investigations in the field of Forensic 
Medicine. 

(e) To aid medical examiners and coroners; 

(f) To assist law enforcement officers in per- 
fecting standards of medical examinations required 
by law ; 

(g) To provide a central office of information 
on medico-legal questions ; 

(h) To assist members in their indemnity insur- 
ance problems ; 

(i) To develop studies, conduct research and to 
advance regulations in employment compensation ; 
and 

(j) To concern ourselves with any and all of 
the branches of legal medicine as they are related to 
the rendering of medical care and preventive medi- 
cine. 

A good idea of the new journal is to be had from 
a perusal of the contents of the present number : 
The Medical Man on the Witness Stand, by Eugene 
O’Dunne, LL.M. ; Blood Grouos in Disputed Pater- 
nity, by Michel Piioan, M.D. ; What Constitutes 
Body Attack in Medical Practice? Herbert V. Bar- 
bour, LL.B. ; The Expert Witness and the Insanity 
Defense Plea, Martin H. Hoffman, M.D. ; The In- 
terpretation of X-rays in Court Hearings, by L. H. 
Garland. M.D. ; Organized Society’s Interest in 
Death, Oscar T. Schultz, M.D. ; Detailed Examina- 
tion Required to Determine Whether Rape has been 
Committed, J. R. Garner, M.D. ; Doctors, Juries, 
and Judgments, Paul E. Craig, M.D. ; and Diagnosis 
and Treatment of Legal Congestion, by Alfred 
Koerner, M.D. In addition to these is an interesting 
and timely paper on The Coroner and the Medical 
Examiner, prepared by the National Research Coun- 
cil of the National Academy of Science. Then fol- 
low special departments, namely, Editorial, Across 
the Editor’s Desk, in which the editor assumes a 
more personal approach to his subject, Current 

53 


EDITORIAL 


Comment, In the Courts, In the Legislature, Open 
Forum, Book Reviews and Abstracts. 

Number 1, Volume I, is of absorbing interest. It 
sets a high standard for succeeding numbers. The 
editor’s long experience as secretary of the Michi- 
gan State Medical Society and editor of its Journal, 
as well as his years as speaker of the House of 
Delegates of the A.M.A., admirably qualify him for 
this latest venture in specialized journalism. 


SHOULD RADIOLOGY AND PATHOLOGY 
BE INCLUDED AS BENEFITS IN 
HOSPITAL INSURANCE PLAN? 

Radiology and pathology are definite, legitimate 
specialties and their practitioners are consultants, 
possessed of much highly technical post-graduate 
training and are entitled to an equal consideration 
and standing accorded to those engaged in other 
recognized specialties. There is no justification in 
forcing them into the degraded roll of “come-bns” 
or their services offered as additional inducements 
for the purpose of increasing policy sales. 

Not more than ten per cent of legitimate hospital 
patients require any form of x-ray and only twelve 
per cent require any but the simplest laboratory in- 
vestigations, hence, there is very little total benefit 
to policyholders. Would it not be more sensible to 
give them an additional day or two hospitaliza- 
tion? The inclusion of some professional services 
will most certainly pave the way for the inclusion 
of more and broader practice of medicine by hospi- 
tals, as was so graphically pointed out in an editorial 
in the State Journal a few weeks ago. This would 
destroy more and more the age-old doctor-patient 
relationship which is the fundamental basis for all 
good medical practice. 

It is argued that charges for x-ray and patho- 
logical services are now commonly included in the 
hospital bill and the patient will expect them to be 
included in benefits. It seems to us that this is a 
rather inane argument. Charges for oxygen, insulin, 
unusual dressings and drugs, board for special 
nurse, etc., are also included in a hospital bill, but 
all plans very definitely class these as extras and 
they are not included in benefits. 

The success of a hospital insurance plan does not 
depend on x-ray and pathological benefits. The Bay- 
lor plan, one of the oldest and continuously most 
successful of all plans, does not and never has in- 
cluded professional services in any form or guise. 
In Wichita, Kansas, and Nashville, Tennessee, there 
are thousands of policyholders who pay extra for 
x-ray and pathological charges, if, when, and as 
needed. There are numerous other such plans equal- 
ly successful, working with full cooperation of the 
medical profession and giving only true hospital 
expense coverage. These are the reasons why or- 
ganized radiology and pathology, including all na- 
tional organizations, are vehemently opposed to be- 
ing included as benefits. In this they are strongly 
supported by the published policy of the A.M.A. 

Insurance coverage for medical attention in acci- 
dent and sickness is another separate and distinct 
matter and may eventually be worked out in a man- 
ner which will prove to be feasible. A definite ad- 
vance was made in this direction as presented in the 
Mutual Health Service plan submitted in 1934, which 
we would do well to consider carefully. When the 
time comes the services of the radiologist and the 
pathologist will naturally be included on the same 
basis of the practice of medicine. — Genesee County 
Medical Bulletin. 


WARNED IN TIME 

[“Herr Julius Streicher, addressing a thousand members 

of the Nazi Welfare Medical Administration at Munich, 

suggested that Herr Hitler and Signor Mussolini were great 

because they were non-smokers.” — News item.] 

Tobacco is a noisome weed (Herr Streicher he has 
said it), 

And from its victims there proceed no men of 
worth and credit ; 

Though Bismarck puffed, and even snuffed, and 
kept cigars a-going, 

He was a dud — his name is mud on Streicher’s lat- 
est showing. 

The men of State, the good and great, avoid those 
hideous vapours ; 

Their names appear all bright and clear on His- 
tory’s page and papers. 

Tobacco jars and fat cigars both fall beneath their 
veto ; 

They scorn all types from fags to pipes, like Adolf 
and Benito. 

And yet beware — if that bright pair of dictatorial 
jokers 

Now represent the mood and bent achieved by 
staunch non-smokers, 

Why, some may flock to fill, restock their smoking 
store or larder, 

Resolved to miss that doubtful bliss by smoking 
all the harder. 

— Manchester Guardian. 


PARIS PHYSICIANS PROTEST AGAINST 
SOCIAL INSURANCE 

The abuse of free medical care by the public 
hospitals and dispensaries and the illegal extension 
of the original function of the social insurance au- 
thorities are arousing the French medical profession 
to make a virgorous campaign to put an end to a 
movement which renders it difficult for physicians to 
earn a living, the regular Paris correspondent of 
The Journal of the American Medical Association 
reports in the Dec. 10 issue. In the notice sent out 
by the association of physicians in the department 
of the Seine, in which Paris is situated, for a meet- 
ing to be held Nov. 4, 1938, the following plea was 
made for a full attendance : 

It is becoming more and more difficult, in fact 
almost impossible, to practice in Paris and the ad- 
jacent areas. 

The public hospitals and dispensaries, which are 
not subjected to the excessively high taxes which 
physicians must pay, are doing all they can to give 
free medical attention without any inquiry as to 
the ability of the sick to pay. Such institutions 
should treat only indigents. 

The social insurance organization was created to 
insure the worker earning up to a certain sum an- 
nually, now 30,000 francs, so that he might be able 
to pay for medical care. Instead of limiting their 
activities to this commendable objective, the social 
insurance authorities have begun to make serious 
inroads on the work of private practitioners by 
attempting to organize facilities for treating the in- 
sured worker. Every effort is being made to turn 
the insured from specialists and general practition- 
ers by urging them to enter public hospitals or re- 
ceive treatment at the many public dispensaries. 

The situation has become so acute that the time 
has arrived for a more energetic campaign against 
these abuses, which make it impossible for a physi- 
cian, after many years of preparation, to compete 
with the tendency toward state medicine. 

Jour. M.S.M.S. 


54 



EN ALERTE 


T O BE ALERT, to be aware, to be prepared for the duties ahead 
is winning more than half the battle. 

By the time this page reaches the membership, it is anticipated that 
the House of Delegates will have taken positive action covering some 
phases of the medical problems. However, this is only a small part. 
We are continually faced with numerous attempts to experiment with 
the distribution of medical service. It can be reasonably anticipated 
that much medical service legislation will be under consideration 
this session of the State Legislature. Efforts to modify the basic 
science law, changes in the afflicted child law, provisions for medical 
relief to governmental assistance groups, extensions of Public Health 
Departmental activities and numerous other topics are definitely on 
the legislative programs. 

Any developments that may occur must be patterned after Ameri- 
can methods, individual responsibilities and free enterprises. 

Your State Society officers and committees are working endless 
hours and sacrificing health and means with two objectives in view. 
The first is that the distribution of medical care to the people of the 
State of Michigan be of the best quality and adequate for their needs. 
The second, that the economic security of the physician, opportunity 
to improve his scientific knowledge and his welfare be adequately 
safeguarded because the physician is the keystone of the Arch of 
Health and without a sturdy keystone the arch will fall. 

It is the duty of every member of the Society to inform himself 
thoroughly of all activities involving the health of the public, to be 
alert to the possibilities of legislation inimical to the general welfare, 
and to contribute his share personally towards attaining our objec- 
tives. Do not leave the task to the Legislative Committee alone — 
make yourself a committee of one herewith appointed by 


Yours truly, 



President, Michigan State Medical Society 


January, 1939 


MEDICAL STAFF CONFERENCES 


“The Department of Internal Medicine is this year (1938) inaugurating a series of weekly Medical Staff 
Conferences, the first of which was held in the Hospital Amphitheatre on October 7 at 4:00 P. M. These 
meetings are to be attended by all the members of the staff of the department and they are also open 
to members of other departments, the faculty of the Medical School and visiting doctors. The con- 
ferences are not open to medical students except by special invitation. 

‘‘The present arrangement is to have two patients from the Medical Service presented at each con- 
ference. These patients are selected at a weekly meeting of the Assistant Residents from the various 
Medical Wards and the Tuberculosis Unit and the Intern at Simpson Memorial Institute with Dr. Bert 
Bullington. Interesting cases from the Out-Patient Department may also be suggested by any member 
of the staff. A brief abstract of the history, physical examination and laboratory data is prepared by 
the physician in charge of the patient and mimeographed copies are distributed at the Conference. The 
meetings are presided over by Dr. Cyrus C. Sturgis, or in his absence either by Dr. Henry Field, Tr., or 
Dr. Paul S. Barker. All the discussion in regard to each patient, including all relevant references to recent 
and important literature, is recorded, typed and attached to the patient’s record .” — University of Michi- 
gan Medical Bulletin. 


Medical Conference, October 7, 1938. Patient, 
G. P., No. 429756. Presented by Dr. Kenneth M. 
Smith. 

Dr. Cyrus C. Sturgis : The earliest symptom 

was pain in the eyes followed by swelling which 
completely closed them. At that time she also had 
fever. It was because of these symptoms that she 
came to the University Hospital and was admitted 
to the Eye Department. The ophthalmologist asked 
for a neurological consultation, but no neurological 
lesion was found, whereupon she was referred to 
the Department of Internal Medicine f'or examina- 
tion. Dr. Howes, who saw her, suspected trichi- 
nosis, although no differential blood count was avail- 
able at that time. She was then transferred to 
Medicine. Her temperature had been between 101.8 
and 102.8 degrees (F.), gradually decreasing to 
normal on the third hospital day. 

Dr. Kenneth M. Smith : On October 4, 1938, 

the patient had a tonsillectomy (because of a chron- 
ic tonsillitis). The pathology report (by Dr. 
Weller) described areas of focal myositis with 
eosinophilic infiltration, pathognomonic of trichinosis. 
Another specimen showed encysted trichinella 
spiralis in the pharyngeal muscles. 

Dr. Cyrus C. Sturgis : The blood examination 

on the 6th of October showed a white blood count 
of 6,800 with 26.5 per cent eosinophils. She is now 
recovering very satisfactorily, she looks well, and 
there is no muscle soreness. At first the muscle 
soreness was very severe, so much so that it was 
painful for her to straighten out her legs. The 
presence of muscle soreness, puffiness of the eyes, 
fever and eosinophilia at once suggests the diagnosis. 

The reasons for presentation today are : In the 
first place, this is the third case of trichinosis that 
we have seen in the last few months. One very in- 
teresting case recently seen, which came to autopsy, 
showed the presence of trichinae throughout the 
body, including the myocardium. The second rea- 
son is that we have used the .skin test as a 
diagnostic measure. This test is very simple to per- 
form, it can be read easily, an area of induration 
with surrounding erythema indicates a positive re- 
sult. This test is helpful in the diagnosis because 
about 50 per cent of the muscle biopsies in these 
cases are reported as negative. Dr. Bullington has 
collected considerable data concerning this disease 
in cases seen in this hospital since 1926. 

Dr. Bert M. Bullington : Dr. Field has seen 

most of these cases. Since 1926 there have been 
forty-two cases recorded in the Record Room. Of 
these there were thirty-one active cases ; six were 
diagnosed as incidental findings in the pharyngeal 
muscles removed at tonsillectomy and two of these 

56 


cases diagnosed by tonsillectomy were active at the 
time of tonsillectomy. Four cases were diagnosed 
by incidental muscle biopsy findings (the biopsies 
being performed for some unrelated illness). Three 
cases were picked up as incidental autopsy findings 
(the patients having died of some unrelated illness 
but having active trichinosis at the time of death). 
Thirteen were diagnosed by the clinical findings 
only, the clinical picture being quite definite. The’ 
clinical impression was confirmed by muscle biopsy 
in nine others; two by the skin test plus the clinical 
picture ; one by the skin test and biopsy specimen ; 
one by the clinical picture in addition to finding 
the trichinae in a specimen of pork submitted by 
the patient ; one was diagnosed by the finding of the 
larvae in the venous blood ; one by the presence of 
the parasites in the stool ; and one by the presence 
of the trichinae in the spinal fluid. 

Of these thirty-one active cases, twenty-eight had 
an eosinophilia ranging from 15 to 73 per cent. One 
active case had an eosinophilia of only 4 per cent ; 
two had no differential counts done. In these cases 
thirteen muscle biopsies were done, two on the 
same patient ; ten were positive for the diagnosis ; 
two were suggestive of the diagnosis, and one was 
negative — which is not in harmony with reports 
from the literature that more than 50 per cent of 
muscle biopsies are negative. 

We have done but four skin tests. Three were 
immediately positive and one questionable reaction; 
that reaction was not read until twenty-four and 
forty-eight hours, at which time erythema was 
present at the site of the injection. Three patients 
had meningitis — that is, trichina meningitis. One of 
these patients with meningitis recovered. Two pa- 
tients had myocarditis, as evidenced by electro- 
cardiographic .studies, two had myocarditis shown 
by the pathological specimen. One had repeated 
hemoptyses, one had a terminal hemorrhagic state, 
and died after a brisk hemorrhage from the ears, 
nose and mouth. At autopsy a subdural hermatoma 
was found. One patient had a false positive Kahn 
on two occasions ; two Kahn reactions later were 
negative. 

Dr. Cyrus C. Sturgis : Dr. Smith, do you have 

information regarding the Federal regulations con- 
trolling pork inspection? 

Dr. Kenneth M. Smith : The Federal regula- 

tions at the present time are not very stringent. It 
is required, however, that all pork products which 
are to be eaten uncooked have to be boiled, by the 
producer. This is particularly true of ham. which 
must be heated to 137°F. Trichinae are killed by 
a temperature of 58°C. Pork is not directly ex- 
amined for trichinae, hence the stamp of “U. S. In- 
spected and Passed” means nothing insofar as pro- 

Jour. M.S.M.S. 


MEDICAL STAFF CONFERENCES 


tection against trichinae is concerned. It is, there- 
fore, advisable to cook all pork well. 

Dr. Sturgis : This disease is not so uncommon. 

Are there any data about the study of muscle tissue 
in routine autopsies in patients who have died of 
various diseases? 

Dr. Kenneth M. Smith : There is considerable 

amount of work that has been and is being done 
in this respect. In a series of 200 routine autopsies 
in San Francisco, trichinae were found in 23 per 
cent of the cases ; 344 autopsies in Rochester showed 
an incidence of 7.5 per cent ; in Boston 27.6 per cent 
of fifty-eight autopsies ; and in a recent study in 
Washington of 300 cases the incidence was 13.6 per 
cent. 

Dr. Lloyd Catron has studied muscle specimens 
in 300 autopsies at the University Hospital. There 
had been no symptoms of trichinosis but trichinae 
were found in 15 per cent of the specimens. There 
are many other similar statistics. Hall and Collins 
found an incidence of 12.5 per cent in 1,778 cases. 

Dr. Cyrus C. Sturgis : We might substitute the' 

diagnosis of influenza for trichinosis for the lack 
of a better diagnosis in those individuals who have 
fever and muscular aching but no puffiness of the 
eyes. 

Are there any data as to the death rate in this 
disease? 

Dr. Kenneth M. Smith : The death rate in 

central Ohio epidemic of ninety-six cases was 8.3 
per cent and in a Maine outbreak of fifty-six cases, 
two were fatal. 

Dr. Cyrus C. Sturgis : Have there been any ex- 
perimental studies directed toward treatment? 

Dr. Kenneth M. Smith : Bachman attempted 
immunization of rats against trichinella spiralis and 
found that only temporary protection could be 
given by feeding increasing dosages of infected 
meat. He also attempted to protect rats by injecting 
anti- and convalescent sera, feeding trichina powder, 
and by the intraperitoneal injection of a Coca’s 
suspension of finely ground larvae, but was unsuc- 
cessful in all attempts. Semrad exposed trichinella 
larvae to x-ray irradiation (800 r units) ; although 
they were not killed they showed an inability -to 
reproduce. 

Miller studied a number of drugs which had been 
reported as therapeutically useful. Intravenous 
neoarsphenamine, antimony and potassium tartrate, 
acriflavine base, Rivaral, gentian violet and iodine 
had no therapeutic effect on experimentally infected 
animals. 

Wantland found that cysts begin to form around 
the coiled larvae, in the muscles, in four to six 
weeks ; these cysts become calcified in seven to eight 
months. Symptoms arise from unencysted larvae 
and death from trichinosis occurs within the first 
four to six weeks of the disease. We know' that 
irradiated ergosterol increases the absorption of 
calcium from the intestinal tract. With this in 
mind he treated infected rabbits with calcium lactate 
and irradiated ergosterol. The calcification of the 
cysts was found to occur more rapidly, being com- 
pletely so in 3 months instead of the usual period 
of eight months. The treated animals showed a re- 
turn of their normal appetite much earlier than the 
non-treated ones. 

Dr. Cyrus C. Sturgis : Dr. Field, according to 

Dr. Bullington, saw most of the trichinosis patients 
in this hospital. Perhaps he has something to offer? 

January, 1939 


Dr. Henry Field, Jr. : There are two patients 

that I recall that are of some interest. These two 
had presenting symptoms of fever and swelling of 
the lids. Both of them had no eosinophilia on ad- 
mission. The diagnosis was suspected because of 
the association of fever with swelling of the lids 
with no other apparent cause of the edema. Re- 
peated blood counts showed the development of 
eosinophilia. Therefore the absence of eosinophils 
on admission does not exclude the diagnosis. 

I would like to know if there is any information 
about what the skin test would show in patients 
infected five to ten years ago? 

Dr. Sturgis : I believe Dr. Bullington has some 

information about how long the skin tests have re- 
mained positive. 

Dr. Bullington : One report by Spink stated 

that some of the cases who gave a definite history 
of infection six to seven years ago, recently tested 
(in January, 1937), still had positive skin tests but 
the number of positive tests was low. Other in- 
dividuals who ran tests on 82 cases in epidemic five 
years ago, found that all had negative skin tests. 

Dr. Sturgis : But it may be positive after several 
months or years? 

Dr. Bullington : In all probability it is positive 

for several months and perhaps two to three years. 

In December, 1936, and again in January and 
February, 1937, there were two rather severe epi- 
demics in the state of Michigan : one at Rogers 
City and one at Capac. There were thirty-two cases 
at Rogers City and seventy-two at Capac. One of 
our patients came from Rogers City. 

Dr. Sturgis: What was the mortality? 

Dr. Bullington : The only data available were 

from Capac. There were six fatalities ; thirty-three 
severe cases ; twenty moderately severe ; thirteen 
mild cases. 

We had one interesting family in our study. The 
father, who was very severely infected, died and 
the mother died of meningitis before she was ad- 
mitted. There was one son on the medical wards, 
one daughter and one son on the pediatrics service ; 
all had the disease quite severely. 

Dr. Sturgis : Can you tell us why there are two 

reactions to be expected — the immediate and de- 
layed? 

Dr. Bullington : The skin test is an allergic re- 

action. The antigen that we use is in two dilutions, 
1 :500 and 1 : 10,000, having been obtained from the 
Michigan State Department of Health. This is an 
extract of the trichinae in Coca’s solution. A con- 
trol of Coca’s solution should always be used. In 
cases of a duration of 18 days or longer an im- 
mediate reaction is expected, becoming positive 
within a few minutes and usually disappearing after 
two hours. If the disease is of shorter duration — 
four to twelve days — a positive reaction is to be 
expected only after twenty-four hours wdthout any 
immediate reaction. 

Dr. Sturgis : What is the composition of Coca’s 

solution, Dr. Sheldon? 

Dr. John M. Sheldon : Coca’s solution contains 

2.5 grams sodium bicarbonate, 4 grams phenol and 
5 grams of sodium chloride made up to 1,000 c.c. 
with distilled water. 

Dr. Sturgis : At a medical meeting last year, Dr. 

57 


MEDICAL STAFF CONFERENCES 


Fred Smith reported a series of cases of myocardi- 
tis. He showed some sections supposedly having an 
obscure etiology. Dr. Weller, who was present, 
suggested that it appeared to be trichinosis of the 
heart. 

Dr. Arthur C. Curtis : A few years ago, a 
small epidemic of trichinosis occurred in St. Joseph, 
Michigan. Dr. Kerlikowske and I happened to be in 
St. Joseph at that time. The members of one family 
that we saw were very ill. The onset of the illness 
had been with a high fever and a very severe diar- 
rhea. They were being treated at that time as in- 
fluenza. The blood differential count did not show 
an eosinophilia during the early period. When an 
eosinophilia developed, the local physician suspected 
the diagnosis and asked me to see the case. It was 
the most severe type of the disease, with profound 
diarrhea and considerable contracture of the muscles 
of the extremities. This latter feature was .so great 
in the father, who was very well muscled, that he 
lay in a position as if he held heavy weights in 
each hand. His neck was also rigid. The father 
died, as did the mother. Only one survived, that 
being a young boy. Their temperatures were 105- 
106° F. 

Diarrhea seems to be an index to extent of in- 
vasion. Minor invasion may occur without diarrhea. 

Dr. Bullington : One patient in our series had 

Hirschsprung’s disease. At autopsy his entire in- 
testinal tract was heavily infested with trichinae. 


Anti-vivisection Again 

(New York Times) 

It is an honorable medical principle that before a 
new method of treating disease is introduced it must 
be tested not only on animals but on animals closely 
related to man. To adopt any other procedure is 
to slip back to the Middle Ages, when even the 
dissection of cadavers was forbidden. Diphtheria, 
syphilis, pneumonia, pellagra, pernicious anemia, 
smallpox, all the afflictions caused by deficiencies in 
vitamins and hormones or by bacterial infection 
would still be insoluble riddles if it had not been 
for researches carried on with the aid of dogs, 
guinea pigs, rats and monkeys. If ever cancer and 
tuberculosis yield to medical treatment it will be 
solely because biologists and chemists have put their 
theories and their preparations to the test on 
animals. A billion rats is no price at all to pay 
for even the dimmest light on the cause of cancer. 

Despite these oft-presented facts the anti-vivisec- 
tionists are making a new attempt to thwart ex- 
perimental medical research, this time in California. 
There the voters will be asked on Nov. 8 to ballot 
on what is called a “humane pound law.” Any one 
who keeps animals, except for sale, will become a 
“poundmaster.” As such he may not use domestic 
animals for experimentation. If this proposal is 
approved the laboratories will have to breed their 
own animals, a procedure which is impractical be- 
cause of the numbers that are needed. Moreover, 
it will be difficult for the makers of vaccines, vita- 
mins, hormones and chemicals for medical use to 
test their products before placing them in drug 
stores, with the result that phyisicans could not be 
.sure of the efficacy of the medicines that they pre- 
scribe. That thousands of half-starved, uncared for 
and unwanted dogs roam the streets and back 
yards to fall a prey to official dog-catchers and 
meet death in city pounds seems to be ignored. 

“If you do not kill this measure it will kill you” 
is one of the slogans under which California biolo- 
gists and medical men are fighting the “humane 
pound law.” And the slogan is true. Interference 
with the right to reduce human suffering and to 

58 


lengthen the span of life by the most effective way 
thus far discovered is suicidal. Between dogs and 
babies^the choice is easy. “An intelligence test for 
voters” the Californian measure is called by its 
sponsors. If there is any intelligence in California 
it will meet the test by repudiating a device for 
checking medical progress. 


For Early Diagnosis of Cancer of the Cervix 

(New York State Journal of Medicine) 

It is in this sense that we can consider the 
Schiller test for the detection of early cancer of 
the cervix. Following exposure of the part and 
cleansing, a generous quantity of Gram’s solution is 
applied to the cervix and permitted to stay in con- 
tact with it for at least five minutes. Differentia- 
tion between normal and cancer cells is demonstra- 
ble by the deep brown color of the former, in con- 
trast to the lighter color of the latter, which appear 
as whitish spots. This reaction is the result of the 
glycogen deficiency of cancer cells. According to 
De Lee, also Watkins, this test should be performed 
on women in middle age at least once yearly. 

When it is realized that the incidence of cancer 
of the cervix is second only to mammary cancer, 
this simple test is a distinct advance in early diag- 
nosis. By this means, treatment can be instituted 
at the earliest possible time and an increase in the 
number of “cures” can be hoped for. The sim- 
plicity of the test makes it readily applicable by 
the general practitioner. 


Election Portents 

(New York State Journal of Medicine) 

It is true that the outcome of the elections may 
give thought to the Administration in Washington 
and persuade it to reform the reforms it has al- 
ready instituted before undertaking additional has- 
tily concocted experiments. If counsels of modera- 
tion prevail, there is hope that the profession will 
be given an opportunity to work out a sound, long- 
range plan in conformity to actual needs. The fact 
that the nation’s health keeps reaching a new high, 
year after year, denies the existence of an emer- 
gency and proves that the present system is neither 
obsolete nor incapable of adaptation to new condi- 
tions and requirements. 

Whatever the course followed at Washington, 
New York State should stand firm on the principles 
which have given it first place in public health. It 
leads the rest of the country in this field because 
it has kept the medical profession as its chief health 
adviser. Let it abandon this qualified counselor for 
inexperienced social theorists and it will become 
entangled in costly bureaucratic schemes which will 
lower the comparatively high standards of medical 
care enjoyed by workers here to the low level pre- 
vailing in most health insurance countries. 


A Nazi Joke 

It appears that Dr. Schacht visited Montagu 
Norman, governor of the Bank of England, and re- 
quested a loan of £50,000,000. 

“What is your security?” asked Mr. Norman. 

“Well, underground we have our unexploited iron 
and coal, and above ground, as a guarantee for this 
collateral, we have our Fuehrer 

“If you could reverse the conditions I might be 
able to accommodate you,” replied the governor of 
the bank. — Moncton Transcript. 


Jour. M.S.M.S. 


The Business Side of Medicine 


c<?o 




LIFE INSURANCE AS INVESTMENT 

By Henry C. Black and 
Allison E. Skaggs 

E VER since the beginning of time, men 
in all walks of life have been engaged 
in a struggle for economic security. Since 
history began, we have sacrificed something 
Today that we may have something Tomor- 
row. Modern man stores money with which 
to buy goods. His savings are placed in 
savings banks, building and loan associa- 
tions, stock exchanges, mortgage loans, real 
estate, investment trusts, government 
bonds, and life insurance. 

The subject matter in this article is being 
confined to an analysis of life insurance as 
an investment. The statement is sometimes 
made that “life insurance is all right for 
protection, but isn’t a good investment.” 
Occasionally this statement is made by per- 
sons otherwise well informed on financial 
matters. The purpose of this article is to 
consider the attributes of an ideal invest- 
ment in its application to the life insurance 
investment. 

Our first consideration is Safety of Prin- 
cipal. In this respect there has never been 
the loss of a single penny to a policy holder 
by any mutual legal-reserve life insurance 
company, organized as such. The vast ma- 
jority of life insurance companies in Amer- 
ica today operate under the mutual legal- 
reserve system. 

Our second consideration is Reasonable 
Rate of Return, consistent with dependable 
safety. In this respect it is found that the 
rate of return of the life insurance invest- 
ment has been exceedingly good. Most 
companies guarantee 3% or 3ty% under 
their contracts. The average rate has been 
considerably higher due to the payment of 
excess interest earnings under the mutual 
principle, over and above the guaranteed 
rate of return. 

Our third consideration is Regularity and, 
Stability of Income. The life insurance in- 
vestment rate is likely to maintain the high- 
est level of interest rates consistent with ab- 
solute safety. The life insurance portfolio 
represents an accumulation of purchases 

January, 1939 


over a long period of time, thus containing 
many long-running bonds of high yield, ac- 
quired at a favorable time. 

Our fourth consideration is the Avoidance 
of Managerial Care. The handling of an 
investment account involves experience, 
skill, watchfulness, and power of analysis. 
Outside of the premium payment, the in- 
sured is freed of all managerial care such as 
investigation, analysis, appraisal, spread of 
risk, re-investment, and collection of in- 
come. Also burdens of a routine nature, 
responsibility, and worry. 

Our fifth consideration is N on- fluctua- 
tion in Value. The life insurance invest- 
ment, represented by the cash value of the 
contract, always remains at the promised 
amount. Life insurance is a depository in- 
stitution, based upon the law of averages as 
it relates to investment. It is rated “A.” 
The uncertainty in the price of a good bond 
is due, in part, to the certainty of the inter- 
est payment. In life insurance there is no 
fluctuation. 

Our sixth consideration is Proper Spread 
of Risk and Avoidance of the Dangers of 
Individual Selection of Investments. The 
average investor in bonds, stocks, mortgage 
loans, etc., is subjected to much inconven- 
ience and expense by way of investigation, 
collection of dividends, and the payment of 
minimum commissions. Most investors 
cannot diversify sufficiently to apply the 
law of averages. The life insurance port- 
folio represents the application of averages 
with respect to sheer number of invest- 
ments, different economic interests, geo- 
grapic location, maturity of obligations, and 
time of purchase. In life insurance there 
is no individual selection of investments. 
Any losses suffered are more than counter- 
balanced by gains in other directions. 

Our seventh consideration is Protection 
against Claims of Creditors. Most states 
exempt life insurance payable to a desig- 
nated beneficiary against the claims of cred- 
itors of the insured. Our eighth considera- 
tion is Ready Marketability at Par. A 
good investment has marketability. Life 
insurance meets this requirement in full, 
after the surrender-charge period has ex- 


59 


BUSINESS SIDE OF MEDICINE 


pired. In practice, the promised cash values 
are payable upon demand. 

Our ninth consideration is Suitability » for 
Quick Borrozving. The cash accumulations 
on a life insurance policy may.be borrowed 
on without delay or publicity at a guaran- 
teed rate of interest, usually 6%, for the 
full amount of the cash value. There is no 
demand for repayment. Sompared to 
other forms of collateral, the njargin of 
safety is exceptionally low. 

Our tenth consideration is Favorable 
Taxation Treatment. The owner of a life 
insurance or annuity policy receives very 
favorable tax treatment at the hands of 
both the Federal and State governments, 
specific federal estate tax exemptions being 
granted in addition to the general exemp- 
tions. Similarly, state inheritance tax laws 
make similar exemptions available to the 
holder of life insurance and annuity con- 
tracts. It is the only form of property 
which can be made completely exempted 
from federal estate and state inheritance 
taxes by proper arrangement. 

Our eleventh consideration is Favorable 
Denomination. Life insurance is issued in 
convenient units, both as to amount and 
mode of payment. It meets the situation of 
convenience for all people. 

Our twelfth consideration is Acceptable 
Duration. Investors like investments that 
run over a considerable period of time. 
The life insurance investment meets this sit- 
uation. Contracts ranging from five years 
to one’s age of 96 years may be purchased. 
Further, once a policy has been purchased 
and the owner desires to mature the invest- 
ment earlier, he has access to the cash sur- 
render value. 

Our thirteenth consideration is Possibil- 
ity of Speculative Gain. Life insurance is 
non-speculative from the standpoint of the 
promised cash value. From the standpoint 
of a premature death, there is a large ap- 
preciation of principal. It is always in fa- 
vor of the policyholder. In this respect it 
may be likened to a convertible bond. 

Our fourteenth consideration is Full Ti- 
tle to a Part. The life insurance invest- 
ment is not an instalment plan of invest- 
ment. It is a series of separate, distinct 
entities, each one complete in itself and con- 
veying 100% title thereto, after full legal 


reserve surrender values are granted. Un- 
der instalment investments (bonds, stocks, 
real estate, etc.) this is not true — title does 
not pass until completion of the purchase- 
paying period. 

Our fifteenth consideration is Conven- 
ience of the Instalment Plan. Although not 
constituting an instalment plan of invest- 
ment in the strict sense, yet in form, life 
insurance gives all the advantages of an in- 
stalment plan of investment. If death in- 
terferes in the completion of the instalment 
plan, it is completed through the application 
of the decreasing term insurance factor. 

Our sixteenth consideration is Adequate 
State Supervision and Control. One of the 
outstanding sources of investment protec- 
tion is efficient state supervision and con- 
trol. Here the life insurance investment 
stands unexcelled. This supervision and 
regulation is not limited to the statutes and 
departmental supervision of the state in 
which the Company is incorporated or dom- 
iciled, but is exercised in every state where 
the Company writes business. Some legal 
safeguards are: (1) approval of the word- 

ing of contracts; (2) regular state audits 
of Company books; (3) access to Company 
books; (4) character of investments strict- 
ly controlled; (5) the state determines the 
method of valuing assets held. 

Our seventeenth consideration is Ade- 
quate Publicity. Adequate information is 
easily obtainable. The insurance depart- 
ments require detailed periodic reports; the 
essential facts are then published. Policy- 
holder’s inquiries may be directed to the in- 
surance commissioner of his state. The in- 
surance press and insurance publishing com- 
panies give detailed analysis of the financial 
reports of the companies as they are issued. 

Our eighteenth consideration is Correct 
Psylchology. Life insurance enables the 
business and professional man to carry the 
same without devoting time from his busi- 
ness or profession. It represents the slow, 
sure, compound interest method of winning 
a competency, as contrasted to the specula- 
tive method. 

Our final consideration is its Adaptability 
to a Program Meeting Essential Investment 
Objectives: namely, family and business re- 
verses, old age income, liquidation emergen- 
cies, and postmortem emergencies. 


60 


Tour. M.S.M.S. 


DEPARTMENT OF SOCIETY ACTIVITY 

L. Fernald Foster, M.D., Secretary 


FROM THE PRESIDENT-ELECT 

Burton R. Corbus, M.D., Grand Rapids 
President-Elect, Michigan State Medical Society 

Nineteen hundred thirty-eight rapidly draws to a 
close. It has been a worrisome, threatening year. 
Happily, the war clouds of Europe seem less sin- 
ister. The general social and economic situation in 
this country at the moment shows distinct signs of 
improvement. 

The year has brought to the profession of the 
United States a very definite threat of govern- 
mental control of the practice of medicine, vague 
threats in the form of actual plans which would 
reform (sic) the practice of medicine, veiled threats 
in the form of “if you don’t, we will,” and some 
threats not so veiled, as in the unusual and odd 
attempt to obtain a grand jury indictment of the 
American Medical Association on charges made pub- 
lic before the indictment was sought. Distinctly the 
profession has been put on the spot. 

The claim is that the present method of the prac- 
tice of medicine is outworn, yet with all its creak- 
ing, the old machine still seems to work pretty well 
in almost all parts of the country. It must be 
working reasonably satisfactorily if results may be 
taken as evidence, for there has never been a time 
when the mortality and the sick rate figures of this 
entire country has been so low as in 1938. This is 
especially true of Michigan and the neighboring 
state of Illinois. 

We doctors recognize that there is a weakness 
in the distribution of medical care. We recognize 
that some of the traditional methods and activities 
of medical practice have become outmoded. We are 
not averse to change if in this change we can bet- 
ter combat disease, bring a higher degree of health 
to the people, and find a reasonably satisfactory 
life for ourselves. We are proud of the fact that 
in our battle against disease we have made such 
tremendous strides, and in this battle we have had 
less help from the government than the farmer 
has received for the fight against disease in barn- 
yard animals. We would like to see an easier eco- 
nomic approach to the unexpected illness with its 
hospitalization and medical expenses. 

If the reformers will just be a bit patient the 
profession itself will work out this problem. We 
have not been unconscious of the needs, and this 
is especially true of Michigan. Five years ago, we 
brought out our survey of medical service in Mich- 
igan. We had in mind then, as now, the need for 
certain changes in medical distribution. Our social 
objectives are just as definite as are the objectives 
of these altruists and a darn sight more practical. 
We know the patient’s psychology, we know the pa- 
tient’s needs, we are confident that these needs can 
be supplied without the loss of traditional safe- 
guards and guarantees, and without the elimination 
of the traditional and essential doctor-patient re- 
lationship. Government subsidies, yes, for the im- 
poverished, for the prevention of disease, especially 
the contagions, for the education of the public in 
health hygiene in its various aspects, in some in- 
stances perhaps for assistance directed to the fur- 

January, 1939 


ther education of the practicing physician, and of 
course there must be subsidy for the care of the 
insane and the feeble-minded. But we hold that it 
is the right of the patient to choose his own doctor 
and paj 7 him, and we are convinced that where the 
doctor is in competition for the favor or the pa- 
tient, there develops a character and mental growth 
and skillfulness in his art which enables him to 
bring his patient the best service. 

In 1939, it is likely that the profession will be 
confronted with the actuality of definite legislative 
action. Organized medicine is well represented by a 
committee of seven practicing physicians now serv- 
ing as a liaison between the Society 7 and govern- 
ment groups. I believe that we can feel confident 
that in these preliminary meetings this committee 
will show as much tolerance as the situation de- 
mands, as much courage as its obligations to the 
profession and its patients require when adverse and 
dangerous ideas are promulgated, and that they will 
be willing to make concessions where concessions 
must be made and where they can be made without 
sacrifice of principle and without sacrifice of those 
elements which make for self respect, satisfaction 
in work and happiness without which the individual 
doctor cannot grow in character and ability, and 
without which it will be impossible for him to give 
good service to his patient. 

The Michigan profession is not tradition-bound. 
If there is a better way to practice medicine, we 
want to practice it that way. While we do not ad- 
mit that the people of Michigan are suffering from 
a material lack of medical care, we do feel that 
there is a need for an improvement in distribution, 
and we believe that it is possible to work out a 
plan whereby the financial load incident to un- 
expected illness can be lightened without lessening 
the quality of sendee or interfering with the tradi- 
tional ideals of medicine. Michigan will continue 
to exert even 7 effort, through her postgraduate 
courses, to improve the quality 7 of medicine. In 
this practical idealism Michigan has ever been 
among the leaders. 


COUNCIL AND COMMITTEE 
MEETINGS 

1. Friday, December 9, 1938 — Contact Committee 
to Governmental Agencies — Owosso City Club, 
Owosso — 6 :30 p.m. 

2. Sunday, December 18, 1938 — Executive Com- 
mittee of The Council — Hotel Statler, Detroit — 
12 :30 p.m. 

3. Saturday, January 7, 1939 — Executive Commit- 
tee of The Council, Hotel Statler, Detroit — 
6 :30 p.m. 

4. Wednesday and Thursday, January 18 and 19, 
1939 — The Council — Hotel Statler, Detroit — 
10 :00 a.m. 


61 


SOCIETY ACTIVITY 


<f> EXECUTIVE COMMITTEE OF THE COUNCIL <§> 


HIGHLIGHTS: 

1. Group Hospital Service and Medical Care Plans studied for presentation to 
M.S.M.S. House of Delegates. 

2. Plans for M.S.M.S. Convention for 1939 approved; extra <Jay (Friday) added. 

3. Committees of The Council appointed. 

4. T. F. Heavenrich, M.D., resigns as Councilor of 7th District. 

5. Requisites for Associate Fellowship in Postgraduate Medical Education, M.S.M.S., 
widened. 

6. Automobile License Plates for physicians, with “M.D.” thereon, available in 1940. 

7. Possibility of working out agreement with all interested groups re: liens in acci- 
dent cases discussed. 


October 19, 1938 

1. Roll Call . — The meeting was called to order 
by Chairman P. R. Urmston at 2:30 p. m. in 
the Olds Hotel, Lansing, with all members 
present. Also present: Drs. H. A. Luce, 
B. R. Corbus, L. Fernald Foster, J. H. 
Dempster, M. H. Hoffmann, Henry Cook, 
R. H. Pino, Reuben Maurits, H. W. Pierce, 
Don W. Gudakunst, Jos. E. Barrett, and 
Executive Secretary Wm. J. Burns. 

2. Minutes . — The minutes of the meeting of The 
Council, September 20, were read and ap- 
proved. 

3. Financial Report . — The financial report was 
presented and approved. 

The bills payable for the month were pre- 
sented and on motion of Drs. Carstens- 
Moore were ordered paid. 

Analysis of actual expenditures for nine 
months of 1938 vs. Budget estimates was 
presented and studied. 

4. County Clerks’ Assn. Resolution .- — The Chair- 
man of the Contact Committee to Governmental 
Agencies, Dr. Cook, introduced Messrs. Stein 
and Gibbs who presented the resolution of the 
County Clerks’ Assn, re: the pre-nuptial exam- 
ination law. This was discussed generally by 
all present, including the Health Commissioner, 
who stated that no recent complaints had been 
received by his department relative to the law. 
It was felt that any necessary changes, which 
should be made in the future, should be the 
basis for joint consideration by all interested 
parties. 

5. Report from Committee on Distribution of 
Medical Care . — Chairman Urmston reported on 
recent meeting with representatives of hospitals 
in Detroit on October 12, on the action of cer- 
tain Hospital executives in Detroit in forming 
a group hospitalization corporation, and the ac- 
tion of the M.S.M.S. House of Delegates rela- 
tive to group hospitalization, for presentation to 
a future special meeting of the M.S.M.S. House 
of Delegates. General discussion ensued, and 
resulted in a motion by Drs. Carstens-Greene 
that the Committee on Distribution of Medical 
Care be authorized and directed to make a 
further study, to present concrete plans to the 
Executive Committee of the Council, with a 
view to referring same to the House of Dele- 
gates, at the earliest possible moment. Car- 
ried unanimously. 

6. The Chairman introduced Dr. Joseph E. Bar- 
rett, Director, Michigan Hospital Commission, 
who spoke re : the problems of administering 
the state hospitals of Michigan. 

7. Michigan State Nurses’ Association . — A letter 
from this association was read, relative to the 
principle of health insurance. The Executive 
Secretary was authorized to communicate with 


the Secretary of the Nurses’ Association. 

8. Resignation of Councilor T. F. Heavenrich . — 
Dr. Heavenrich’s letter was read. Motion of 
Drs. Carstens-Moore that the letter be referred 
to President Luce, with a view to making the 
appointment of his successor, for future refer- 
ence to the Executive Committee of The Coun- 
cil ; and that the M.S.M.S. Secretary draft a 
letter to Dr. Heavenrich thanking him for his 
years of service and counsel to the Michigan 
State Medical Society. Carried unanimously. 

9. Committee Reports: 

(a) The Joint Committee on Health Educa- 
tion, presented by Dr. Corbus : radio programs 
begin as of Nov. 1, 1938. Dr. Corbus presented 
the problem of talks on mental hygiene, which 
was discussed by Dr. Hoffmann. Dr. Corbus 
also presented the desirability of having the 
chairmen of various committees (Cancer, Ma- 
ternal Health, Mental Hygiene, Radio, and Pre- 
ventive Medicine) meet with the Joint Commit- 
tee on Health Education, and with the Extension 
Division of the U. of M., to discuss talks before 
lay groups and radio talks, the expenses of 
meeting attendance to be borne by the Joint 
Committee. This was approved by the Execu- 
tive Committee of The Council. 

(b) Contact Committee to Governmental 
Agencies : Dr. Cook reported on the complaint 
that the physicians of Wexford County were 
being requested to help defray the expenses of 
employing a clerk to check welfare vouchers — 
this is being investigated. 

Dr. Cook also reported on the possibility of 
working out an agreement with the insurance 
companies and the hospitals re : liens in accident 
cases ; Dr. Cook’s committee was authorized to 
proceed with this endeavor. 

(c) Medico-Legal Committee’s monthly re- 
port was presented; also the monthly report of 
the Maternal Health Committee, the Occupa- 
tional Disease Committee, the Iodized Salt Com- 
mittee, Advisory Committee on T.B. Control, 
Advisory Committee to Woman’s Auxiliary, 
Mental Hygiene Committee and the Legislative 
Committee. 

The Membership Committee report was ap- 
proved, including authorization to reimburse the 
chairman $25 for expenses incidental to steno- 
graphic work in 1937-38. 

Special stationery to be printed for individual 
committees, was discussed, and motion made 
by Dr. Carstens-Greene that no special sta- 
tionery be printed for individual committees, 
without the approval of the Executive Commit- 
tee of The Council. Carried unanimously. 

The suggestion of the Chairman of the Post- 
graduate Medical Education Committee, that 
the chairmen of the Preventive Medicine Com- 
mittee, Cancer Committee, Radio Committee. 

Jour. M.S.M.S. 


62 


SOCIETY ACTIVITY 


Maternal Health Committee, Mental Hygiene 
Committee, and Joint Committee on Health 
Education be made members ex-officio of the 
P. G. Medical Education Committee, as per 
supplemental report of the P. G. Medical Edu- 
cation Committee for 1937-38, was discussed. 
The Executive Committee instructed the Secre- 
tary to inform Dr. Bruce of an action that will 
satisfy his needs re : chairmen of these different 
committees attending meetings of the Committee 
on P. G. Medical Education. 

The Chairman of the Committee on P. G. 
Medical Education referred for consideration 
the addition of two items to the requisites for 
certification for Associate Fellowship in P. G. 
Medical Education, M.S.M.S., these were dis- 
cussed, and finally adopted as follows : 

“11. Membership and regular attendance on ac- 
credited hospital staff conferences 

2-10 units 

“12. Awarding of Fellowships in P. G. Educa- 
tion to members of the Michigan State 
Medical Society on the basis of research 
and teaching activities of the Michigan 
Postgraduate Program ; the first of such 
awards to be made in 1939.” 

Motion of Drs. Moore-Greene that the Execu- 
tive Committee approve the addition of the two 
items as above listed, to the requisites for cer- 
tification. Carried unanimously. 

10. Plans for 1939 Convention in Grand Rapids . — 
Secretary Foster outlined the plans, including 
the same type of program as was successful in 
1938, and extending the General Assemblies to 
include Friday, with an economic talk on Thurs- 
day evening ; the technical exhibit to be arranged 
according to the labyrinth idea; the dates to be 
Sept. 18 to 22, 1939. 

Motion of Drs. Brunk-Carstens that the above 
plans, based on the 1938 experience of general 
assemblies (except for Wednesday morning) be 
approved. Carried unanimously. 

11. State Constitutional Amendment No. 3. — This 
was discussed, and on motion of Drs. Riley- 
Brunk, the principle of restricting appropria- 
tions, as was exemplified in Amendment No. 3, 
was approved. 

12. Welfare Reorganisation. — A letter from the 
W.C.M.S., enclosing a discussion of the welfare 
reorganization bill, with the recommendation 
that same be forwarded in turn to all of the 
county medical societies in Michigan, was pre- 
sented and discussed. The Executive Commit- 
tee of The Council was agreeable that the W.C. 
M.S. send out these statements to the various 
county medical societies of Michigan, and in- 
structed that the secretary so notify the W.C. 
M.S. 

13. Upper Peninsula Medical Society Meeting . — 
Plans for this meeting, being arranged by Dr. 
Foster and Mr. Burns at the request of the 
President of the U. P. Medical Society, were 
discussed. 

14. Automobile insignia for Physicians. — Possibility 
of automobile licenses with “M.D.” thereon for 
doctors of medicine, was discussed. Motion of 
Drs. Moore-Greene that the Executive Secretary 
be authorized to contact the Secretary of State 
relative to the possibility of such insignia for 
1940 and subsequent years. Carried unanimously. 

Membership cards for M.S. M.S. members was 
approved by the Executive Committee, begin- 
ning with 1939, as an aid to registration at the 
annual meeting. 

15. Crippled Children Commission’s Fee Schedule. 
— These schedules, to be promulgated as of 
Sept. 1, 1938, were discussed. The secretary 
was instructed to send a letter to the C.C.C. 


and to the Auditor General, from the Executive 
Committee of The Council of the State Society, 
inquiring as to why these schedules were so 
delayed. 

16. Accident Insurance. — The Executive Secretary 
was instructed to investigate the cost of accident 
insurance on Secretary Foster and Executive 
Secretary Burns, payable to the M.S. M.S. 

17. Reprints of Constitution and By-Laws. — The 
Executive Committee authorized the reprinting 
of 300 copies of the Constitution and By-Laws 
of the M.S. M.S. for distribution to M.S. M.S. 
officers and the Presidents and Secretaries of 
county medical societies. 

18. American Medical Women’s Association. — Sec- 
retary Foster reported on the recent meeting of 
the Michigan Branch of this Association, and 
the misunderstanding resulting from the elec- 
tion. 

19. Adjournment. — The meeting was adjourned at 
8 :15 p.m. 

November 16, 1938, Meeting 

1. Roll Call. — The meeting was called to order by 
Chairman P. R. Urmston at 3 :30 p.m. in Statler 
Hotel, Detroit, with all members present; also 
Drs. Henry A. Luce, L. Fernald Foster, J. H. 
Dempster, Wm. A. Hyland, M. H. Hoffmann, 

G. C. Penberthy, R. H. Pino, and Executive 
Secretary Wm. J. Burns. 

2. Minutes. — The minutes of the meeting of Octo- 
ber 19 were approved as printed. 

3. Financial Report. — The report was accepted and 
bills payable were approved and ordered paid, 
motion of Drs. Carstens-Brunk. 

4. Council Committees. — The Committees as sub- 
mitted by Chairman Urmston were approved, 
as follows : 

Finance Committee : 

H. R. Carstens, Chairman 

V. M. Moore 

H. H. Cummings 

W. E. Barstow 

T. E. DeGurse 

County Societies Committee : 

I. W. Greene, Chairman 

Wilfrid Haughey 

C. D. Hart 

W. H. Huron 

E. F. Sladek 

Publications Committee : 

A. S. Brunk, Chairman 

J. E. McIntyre 

F. T. Andrews 

Roy H. Holmes 

Geo. A. Sherman 

5. Date of County Secretaries’ Conference was left 
to the decision of the Council Chairman, Secre- 
tary, and Chairman of the Legislative Commit- 
tee (set for January 15, 1939). 

6. Committee Reports were presented, as follows : 

(a) Maternal Health 

(b) Health League 

(c) Contact Committee to Governmental 
Agencies 

(d) Occupational Disease 

(e) Preventive Medicine 

(f) Medico-Legal Committee 

(g) Joint Committee 

(h) Radio 

(i) Mental Hygiene 

7. Treasurer’s Report was accepted. 

8. " Brochure on Burns” was presented by Dr. G. C. 
Penberthy and approved, motion of Drs. Car- 
stens-Brunk. 

9. 1939 Annual Meeting Plans were presented. 
Leases were ordered signed, motion of Drs. 
Carstens-Brunk. 


January, 1939 


63 


SOCIETY ACTIVITY 


10. Additional Committee Appointments as made by 
President Luce were approved on motion of 
Drs. Carstens-Riley. 

11. Expenses of Dr. R. G. Tuck for Health League 
were ordered paid, motion of Drs. Greene- 
Carstens. 

12. Notification to all committee chairmen, re: 
clearing of all meetings through the Executive 
Office and notices to be sent by Executive Office 
was to be made by the Secretary, motion of 
Drs. Carstens-Moore. 

13. Auto Emblems, M.D., were announced as avail- 
able from Secretary of State in 1940. 

14. Vote of Thanks was accorded Captain L. A. 
Potter for his activity in limiting cult practices, 
motion of Drs. Brunk-Greene. 

15. An editorial on Election Results presented by 
Editor Dempster was referred to Drs. Luce, 
Corbus and Brunk for editing and approval, 
motion of Drs. Moore-Carstens. 

16. Wayne County Supplement and the Pneumonia 
Brochure were ordered distributed to the 
County Secretaries at the January Conference, 
motion of Drs. Greene-Riley. 

17. The Need for a New Medical Practice Act was 
discussed, and ordered referred to the Legisla- 
tive Committee, motion of Drs. Moore-Brunk. 

Recess for Dinner at 6 :00 P.M. 

Reconvened at 8 :00 P.M. 

18. Committee on Distribution of Medical Care re- 
ported on Group Hospitalization and Medical 
Care Plans : 

(a) Enabling Act 

(b) By-Laws 

The set-up was ordered referred to an expert 
insurance man, the Insurance Commissioner and 
the Committee on Distribution of Medical Care 
for re-draft and reference back to the Executive 
Committee, motion of Drs. Moore-Brunk. A 
vote of thanks was accorded the Committee on 
Distribution of Medical Care for their fine 
work, motion of Drs. Carstens-Moore. 

19. Adjournment at 11 :00 p.m. 


Minutes of Meeting of Officers and Committee 
Chairmen of the Michigan State Medical 
Society with Doctor Corbus, Chairman 
of the Joint Committee on Health 
Education, and Doctor Fisher 
of the University Extension 
Division, Detroit, Monday, 

November 26, Noon 

Present : Doctors R. C. Moeblig, representative 
Joint Committee ; L. O. Geib, Preventive Medicine ; 
Henry Luce; G. C. Penberthy, Radio; H. R. Car- 
stens ; A. L. Brunk ; B. W. Carey, Children’s Fund ; 
A. B. McGraw, Cancer ; C. A. Fisher ; J. H. Demp- 
ster; B. R. Corbus. 

The chairman stated that his purpose in calling 
this meeting was to develop a closer liaison between 
the officers of the State Medical Society, certain 
of its committees, and the Joint Committee, for the 
purpose of increasing the utilization of the facilities 
of the Joint Committee in presenting health educa- 
tion to the laity. He stated that the Joint Com- 
mittee has ever been insistent that there shall be an 
authoritative basis for the material presented in 
health talks. It would seem that the responsibility 
for the presentation of this material should rest 
very definitely upon the various committees of the 
State Society. 

The Joint Committee, through its affiliation with 
Doctor Fisher and the Extension Service of the Uni- 
versity, has the machinery and offers a very special 
opportunity for the dissemination of health informa- 
tion. 


The Committee is prepared to materially expand 
the activities of its Speakers’ Bureau, and asks the 
cooperation of this group. 

In the discussion which followed the following 
subjects and reports were considered: 

1. The function of the various committees in re : 

a. The selection of the personnel which should 
be based on geographical convenience as well 
as on the ability of the speaker to present 
his subject. The names of these speakers 
should be sent to Doctor Fisher for listing, 
or the Committee Chairman should be pre- 
pared to furnish the speaker on request of 
Doctor Fisher. 

b. The group suggests that the Committees — 
Cancer, Mental Hygiene, Maternal Welfare, 
etc. — each prepare a series of talks, or out- 
line of talks, to be placed on file in Doctor 
Fisher’s office, to be sent to the proposed 
speaker, on which he might base his talk. 
(This plan was inaugurated by the State 
Dental Society and has proven most success- 
ful.) 

2. A report by Doctor Corbus on the work of the 
Joint Committee last year. 

3. A report by Doctor Fisher on the work of the 
Joint Committee so far this year, including lec- 
tures to lay groups and radio talks. 

4. A report by Doctor Penberthy supplemented by 
Doctor Fisher, on the activities of the Radio 
Committee. Script for radio talks are sent out 
two weeks in advance. The broad-casting sta- 
tions are cooperating satisfactorily and are ap- 
parently well satisfied with the excellent material 
Doctor Penberthy’s committee has provided. 

5. A discussion by Doctor McGraw concerning 
methods and technics to be used by the Cancer 
Committee in getting information, first to the 
public, and second, to physicians. 

6. A discussion of the possibility of having the 
State Medical Society and joint Committee 
sponsor classes in public speaking. It was sug- 
gested that the Joint Committee might help in 
the organization of such classes and both di- 
rectly and indirectly help to make the project 
possible. The State Society has recognized the 
need for such instruction and is now bringing 
the matter before County Societies. 


HOUGHTON-BARAGA-KEWEENAW 

The December meeting of the Houghton County 
Medical Society was the occasion of a very enjoy- 
able social gathering. Thirty-two persons, members 
and wives, sat down at 7 P. M. to a steak dinner, 
served at the Miscowaubik Club, Calumet, honoring 
the guest of the evening, Dr. S. G. Higgins, of Mil- 
waukee. Dr. Higgins, who spent some time as a 
visiting ophthalmologist to various missions and 
communities in India, gave a very interesting talk 
on customs and dress in India, the conditions under 
which his work was done, and some insight into 
the social and economic conditions involved. His 
talk was illustrated by colored lantern slide views, 
and moving pictures of the people, their homes, and 
customs. 

Dr. Higgins’ collection of articles of dress and 
jewelry in native silver, proved very interesting, es- 
pecially to the ladies. Beautiful Kashmir shawls, 
native saris, and hand-wrought silver bracelets and 
rings, were displayed. 

While the doctors engaged in a _ short business 
session, opportunity was afforded for the subject 
of a medical auxiliary to be discussed by the ladies. 
Much interest was shown, and it was decided to 
hold a meeting for purposes of organization, on the 
evening of the next medical meeting. 

C. A. Cooper, M.D., Sec. 

Tour. M.S.M.S. 


64 


4 WOMAN’S AUXILIARY «#> 

President — Mrs. P. R. Urmston, 1862 McKinley Avenue, Bay City, Michigan 
Sec.-Treas. — Mrs. R. E. Scrafford, 2210 McKinley Ave., Bay City, Michigan 
Press — Mrs. J. W. Page, 119 N. Wisner Street, Jackson, Michigan 


T HE month of November brought two Mid-winter 
Board meetings, that of the national Auxiliary, in 
Chicago, where Michigan was represented by Mrs. 
Urmston and Mrs. Scrafford, and the State Board 
meeting in Detroit which followed that of the Na- 
tional Board. The reports of these two meetings 
follow. These reports should be of interest to 
every member since it is through such meetings 
that our Auxiliary receives its sense of direction, 
determines its objectives and feels the inspiration 
that comes from joining with women throughout the 
country for a common purpose. 

« ’ 

Mid-year Meeting of the National Board 

The National Board meeting of the Woman’s 
Auxiliary to the A.M.A. was held at the Palmer 
House in Chicago, November 11, 1938, at 10:00 
A. M., and was called to order by the President, 
Mrs. Tomlinson. Thirty-two answered roll call. 

Five past presidents and three directors were 
present, also Mrs. Samuel Clark Red, who con- 
ceived the idea of a national Auxiliary. 

In Mrs. Tomlinson’s address she stressed organ- 
ization, spoke of the stability and growth of the 
auxiliary and complimented us all on our coopera- 
tion and enthusiasm. 

Mrs. Rollo K. Packard, Chicago, president-elect, 
spoke briefly but gave no report. Then followed 
the report of the first vice-president, Mrs. Frank 
N. Haggard, of San Antonio, Texas, Organization 
chairman. 

May I explain at this point that the vice-presi- 
dent’s committee is composed of the 2nd, 3rd and 
4th vice-presidents, located in strategic points, there- 
by covering the entire field of activities. 

Mrs. Haggard spoke of the importance of per- 
sonal contacts, lack of interest in medical societies in 
some unorganized states, of difficulties, particularly 
in the Western states, because of the great distances 
to travel. 

As Historian, Mrs. A. E. Barnes of Texas re- 
ported her work of completing data on outstanding 
activities of the Auxiliary from 1934 to 1939, to 
be added to the Pamphlet entitled “The First 
Twelve Years” — 1922 to 1934. It was decided to 
have a committee check, word by word, this addition 
as there were many discrepancies in the recording 
of the original pamphlet. 

The meeting adjourned for luncheon. The guest 
speaker, Dr. Wright, chairman of the Advisory 
Council and a Trustee of the A.M.A., was unable 
to be present, detained at an important meeting. 
In his place, Dr. Bauer, A.M.A., gave the address, 
assuring us that in promoting Hygeia we are in 
no sense book agents, but giving to the public 
information obtainable in no other magazine and 
so necessary at this time. 

He also urged us to be members of as many lay 
organizations as possible and to present authentic 
information on Socialized Medicine. A most in- 
structive address. 

The meeting continued at 2 :00 P.. M. 

Report of special committee on membership 
awards was given by Mrs. Herbert Henkel, Illinois. 
She asked for advice from the Board to determine 
upon what basis this award was to be given. It 
was finally decided to be on a percentage basis. 

There was much discussion as to awards, and a 
motion was made and carried that no awards in the 

January, 1939 


future could be given without the consent of the 
president and Board members. 

Mrs. Lester, Hygeia chairman, reported her goal 
for this year was 15,000 subscriptions. 

She asked Mrs. Herbert, also of Tennessee, to 
explain how they were able to place 6,182 sub- 
scriptions of eight months in Tennessee. Mrs. 
Herbert said a Bill supported by the Public Health 
Commissioner and the Commissioner of Education 
was passed by the legislature. Through this bill 
they were able to place Hygeia in every school in 
Tennessee. 

The state presidents’ reports followed. Outstand- 
ing were Utah, Pennsylvania, New York, Missouri 
and Texas. 

Dr. Wright addressed us just before adjourn- 
ment. He said his message had been given by Dr. 
Bauer, but he wished to assure us of his coopera- 
tion. He emphasized the thought that each state 
has its own problem and wished us every success. 

A very successful meeting adjourned at 6:00 P. M. 

Respectfully submitted, 

Mrs. P. R. Urmston, President 


Mid-year Meeting of the State Board 

The Mid-year Board Meeting of the Woman’s 
Auxiliary of the Michigan State Medical Society 
was held at the Woman’s City Club, Detroit, Michi- 
gan, November 18, 1938. 

The meeting was called to order at 2 :00 P. M. 
by the president, Mrs. P. R. Urmston. 

The following answered roll call : Officers and 

chairmen : Airs. Urmston, Airs. Christian, Mrs. 

Walker, Airs. Scrafford, Airs. Hicks, Airs. Collisi, 
Mrs. Page, Airs. Andrews, Airs. Bond, Airs. Whit- 
ney. County presidents : Airs. Scrafford, Mrs. 

Wenke, Airs. Alter, Airs. Butler, Mrs. Bond, Airs. 
Sutton, Airs. Geib. 

The president, Airs. Urmston, read her report 
of the National Board meeting held in Chicago, No- 
vember 11, which was approved. 

The minutes of the pre-convention and post-con- 
vention meetings were read and approved. 

The Treasurer’s report showed a balance of 
$211.09 and was approved. Reports of the Standing 
Committees followed. Mrs. Jaenichen’s report was 
read by Airs. Harvey. Reports were also given by 
Airs. Collisi, Airs. Walker, Airs. Page, Airs. An- 
drews and Airs. Bond. Airs. Butler reported on 
exhibits. 

There was no unfinished business. New business 
was in order. 

Airs. Urmston reported a communciation from Dr. 
Foster to the effect that the State Aledical Society 
felt that, owing to our growth as an Auxiliary, we 
should finance all of our activities. He also sug- 
gested badges for all members for the State Con- 
vention. Airs. Urmston then proposed, due to these 
suggestions, we discuss a plan for a budget of our 
expenses. Airs. Walker moved, seconded by Mrs. 
Geib, to appoint a committee of five, headed by the 
president and treasurer, to budget expenses. Alo- 
tion carried. 

Airs. Andrews moved, seconded by Airs. Christian, 
to leave the purchase of badges to the Budget Com- 
mittee. Motion carried. 

Mrs. Geib moved, seconded by Mrs. Collisi, that 
only president-elect be sent, with expenses paid, to 


65 


WOMAN’S AUXILIARY 


the national convention. This motion was dis- 
cussed and finally amended by Mrs. Whitney, sec- 
onded by Mrs. Hicks, that both the president and 
president-elect be sent to the national convention 
whenever finances permitted. Motion carried as 
amended. 

The President then appointed the Budget Com- 
mittee — Mrs. Whitney, chairman, assisted by Mrs. 
Hicks and Mrs. Page— their conclusions to be sent 
to the president and treasurer for their approval. 

As there was no further business, Mrs. Sutton 
moved, seconded by Mrs. Andrews, that the meeting 
be adjourned. Motion carried. 

Respectfully submitted, 

Mrs. R. E. Scrafford, Secretary 


Bay County 

The Auxiliary to the Bay County Medical So- 
ciety held its first meeting of the year on October 
12, at the Bay City Country Club. Twenty-six 
members who were present were served an enjoy- 
able buffet supper. This was followed by a busi- 
ness meeting. Outstanding among topics discussed 
were plans for a rummage sale to be held in the 
near furture. Money was needed to “carry on,” 
for the treasury was getting that “lean and hungry 
look.” 

Within a few days following the meeting, the 
committee placed in charge of the rummage sale 
had made arrangements with a local merchant to 
use a vacant store building, rent free, on October 
20 and 21. Considering the fact that we had never 
sponsored such a venture before, the response of 
all members in contributing and collecting material 
was very fine. As a result, our treasury is bulging 
with the seventy-five dollars netted as a profit. 

At the November meeting, held on November 9, 
at the home of Mrs. M. R. Slattery, Mr. William 
J. Burns, Executive Secretary of the Michigan State 
Medical Society, outlined current proposals before 
American and Michigan Medical Societies, particu- 
larly the five major recommendations made by the 
investigating committee headed by Josephine Roche 
at Washington, D. C., in July. He analyzed the 
significance, strength and weakness of each pro- 
posal, suggesting changes which might make them 
more effective. The address was most helpful’ in 
building up a comprehension of the problems of the 
medical profession and an intelligent understanding 
of these problems. 

Mrs. Lynn J. Stinson, 
Corresponding Secretary 


Kalamazoo County 

Mrs. Kenneth Crawford entertained the Woman’s 
Auxiliary to the Academy of Medicine on Novem- 
ber 15, at a cooperative dinner, thirty-six members 
attending. 

Mrs. W. W. Lang gave an interesting report of 
the State meeting held in Detroit. 

Following the business meeting, the group en- 
joyed a review of Margaret Halsey’s book, “With 
Malice Toward Some,” which was ably presented 
by Mrs. Gerald Rigterink. 

Members brought a shower of jams and jellies 
to be distributed in Community Christmas baskets. 

(Mrs. Hugo) Barbara Aach, 
Press Chairman 


Kent County Woman’s Auxiliary 

With 158 members, the largest number ever to 
have affiliated, Kent Countv Auxiliary is enjoying 
a most successful year. Meetings have proved ex- 
tremely interesting and the wide variety of en- 
tertainment is found to be a great drawing card for 
membership and attendance. 

In addition to the delightful talk given by Mrs. 


P. L. Thompson, an auxiliary member, on her re- 
cent round the world voyage, our November meet- 
ing honored our past presidents : Mrs. Thomas C. 
Irwin, Mrs. Burton R. Corbus, Mrs. A. Verne 
Wenger, Mrs. Henry J. Pyle, Mrs. Robert H. Den- 
ham and Mrs. Carl F. Snapp, who all spoke briefly 
and entertainingly on various occurrences taking 
place during their particular regime. 

The December program will also be conducted by 
members and will feature the play reading of “On 
Borrowed Time” under the direction of Mrs. Ralph 
L. Fitts. 

All standing committees are functioning excel- 
lently, and among achivements recently accom- 
plished is the placing of 172 six month subscrip- 
tions of Hygeia in the county rural schools and 
the beginning of a collection of printed articles per- 
taining to medical legislation. 

Jane R. Frantz, 
Press Chairman 


Jackson County 

The November meeting of the Women’s Auxiliary 
was a social one, Mrs. W. E. McGarvey, of the 
social committee, being chairman. The members 
met at the home of Mrs. T. E. Schmidt, and were 
served a 6 :30 dinner. The committee in charge of 
the dinner was composed of the following mem- 
bers : Mesdames C. D. Munro, chairman, R. M. 
Cooley, W. W. Lathrop, R. J. Hanna, and M. J. 
McLaughlin. 

Mrs. R. H. Alter, president, conducted a business 
meeting, at which time suggestions for a project 
for this year were talked over and placed in the 
hands of the project committee. Reports of the 
secretary and treasurer were also read at this time. 

The remainder of the evening was spent in playing 
bridge, the prizes being won by Mesdames Shaeffer 
and Porter. 

Anna Hyde Shaeffer, 
Press Chairman 


Saginaw County 

Mrs. Robert Jeanichen was hostess to forty mem- 
bers of the Saginaw County Medical Auxiliary, 
Tuesday evening, November 15. 

During a short business meeting it was decided 
to place Hygeia in twenty rural schools. 

Mrs. William English, Legislative chairman, gave 
a comprehensive resume of the present trend to- 
ward “socializing medicine.” 

Mrs. Aaron C. Button was winner of the door 
prize drawn during the social hour. Refreshments 
were served by a committee of which Mrs. Henry 
J. Meyer was chairman. 

Mrs. Milton G. Butler, 
Press Representative 


Washtenaw County 

The newly organized Washtenaw County Medical 
Society Auxiliary held its second dinner meeting on 
November 8, at the Michigan Union. Dr. Claire 
E. Straith, a sponsor of the local auxiliary, and Mrs. 
Straith of Detroit were honor guests. 

After a short business meeting, Mrs. Straith, a 
former president of the Wayne County Medical 
Society Auxiliary, told of the present projects and 
accomplishments of that group. 

Later the County Medical Society joined the 
ladies in hearing Dr. Straith’s splendid talk on plas- 
tic surgery. 

A Christmas tea at the home of Mrs. R. Bishop 
Canfield on December 13, and a joint society dinner 
dance in February are included in the winter plans 
by the Auxiliary. 

(Mrs. C. Howard) Cecelia Graham Ross, 

Press Chairman 

Jour. M.S.M.S. 


66 


MICHIGAN’S DEPARTMENT OF HEALTH 


MICHIGAN’S DEPARTMENT 
OF HEALTH 

DON W. GUDAKUNST, M.D., Commissioner 
LANSING, MICHIGAN 


PUBLIC HEALTH CONFERENCE 

The Eighteenth Annual Michigan Public Health 
Conference, held November 9, 10, and 11 at Grand 
Rapids, attracted an attendance of well over 1,200 
members of the health professions and interested lay- 
persons . The official registration of 991 persons 
included 50 health officers, 69 physicians, 50 dentists 
and dental hygienists, 449 public health nurses, 65 
sanitarians, 148 lay members of county health com- 
mittees, 22 laboratories, 14 out-of-state visitors and 
124 representatives of miscellaneous professions. 

The conference opened Wednesday afternoon with 
an address of welcome by Dr. Don W. Gudakunst, 
state health commissioner. Dr. Carleton Dean, of 
Charlevoix, president of the Michigan Public Health 
Association, presided at the session. G. Robert 
Koopman, assistant superintendent, State Department 
of Public Instruction, the first of the principal 
speakers, outlined the scope and objectives of the 
revitalized emphasis upon health instruction in the 
schools which has become a fundamental philosophy- 
underlying the Michigan Curriculum Program. “The 
present plan,” he said, “consists briefly of making 
a direct attack upon the problem in close coopera- 
tion with the State Department of Health and with 
the direct support of the social agencies, profes- 
sional agencies, and foundations interested in health 
education. The prospects of considerable success 
seem brighter than at any previous time.” 

Miss Naomi Deutsch, director of public health 
nursing, Federal Children’s Bureau, termed the 
current national maternal and child health program 
“the American adventure in neighborliness.” “There 
are approximately 7 12,500 maternal deaths in the 
United States each year, of which one-half to two- 
thirds might be prevented if facilities for adequate 
medical care could be everywhere available.” “The 
plan for a national health program to offer more 
adequate health protection and medical care, shaped 
by- the experiences now being built up to extend 
and strengthen health programs should bring assured 
returns in economic stability 7 , in national well-being, 
and in individual contentment throughout our 
country,” Miss Deutsch concluded. 

Discussing “The Role of Government in the Pro- 
vision of Medical Care,” Dr. Gudakunst pointed 
out that government’s role is not the practice of 
medicine, but rather to provide for medical care. 
“Socialized medicine, such as developed in many- 
parts of the world, has no place in our scheme 
of things in this country.” “State departments of 
health,” the commissioner continued, “in fact, all 
health agencies, have become concerned with this 
question of government providing for medical care. 
Health workers are, of course, concerned. They 
have traditionally, and for many, many years, been 
concerned with those factors contributing to the 
death rate, with environmental sanitation and with 
the spread of communicable diseases, but there is 
little satisfaction when you keep people alive from 
one cause and see them die from another cause. 
Therefore, it is quite logical that health workers 
have concerned themselves with this problem. Not 
that they have had hope at any time of putting 
over a program where they, themselves, would be 
engaged in the practice of medicine, but we do hope 
that they can undertake some leadership, on a na- 
tional and state-wide basis and in their own local 

January, 1939 


communities, in bringing together the various forces 
that are existing in those communities so that more 
and adequate service can be administered. * * * 

“Government is concerned, therefore, mainly with 
the payment for sen-ices that the physician has to 
render — not so much concerned with the quality. 
Of course, interested; of course, very much con- 
cerned in one way, but not concerned to the point 
where government can say, ‘We,’ or as more fre- 
quently happens, ‘I am able to practice medicine 
much better than anyone else.’ That is not govern- 
ment’s concern. It is government’s concern to make 
available the money for the payment of services 
which the physician has to render. Any relation- 
ships that are worked out must be on an equitable 
and satisfactory- basis, satisfactory to the medical 
profession itself. There must be reasonable pay 
for sen-ices. We cannot continue, as we have in 
many places in some of the feeble attempts to 
meet this problem, to pay- the physician at a very- 
small fraction of what his sen-ices are worth. 
When we do that we quickly prostitute the practice 
of medicine. When an office service is paid for at 
the rate of fifteen cents, the patient gets fifteen 
cents worth of sen-ice ; and obstetrical sen-ice can- 
not be rendered for the payment of a few dollars. 
The relationships that are worked out for the pay- 
ment of these sen-ices must be equitable and reason- 
able for the physician.” 

Dr. Carl E. Buck, field director of the American 
Public Health Association, speaking on “Organizing 
Your Community Resources for Health,” urged the 
directors of every- local health department to secure 
the appointment of a public health committee by the 
local medical society-. “Most of the difficulties that 
occasionally- arise between the public health group 
and the organized medical profession would be 
avoided if we had a close liaison between the public 
health department and the public health committee 
of each local medical society,” he declared. 

Dr. William S. Sadler, director and chief psychi- 
atrist of the Chicago Institute of Research and Diag- 
nosis, addressed the enthusiastic Wednesday evening 
session on the subject of “Mental Hygiene.” Psychi- 
atry today,” he declared, “is something more than 
medical psychology-. True, it started that way-, but to- 
day- psychiatry- is what I prefer to call ‘Personol- 
ogy .’ * * * It is the person we are dealing with 

— more and more it is the whole person. Sooner 
or later some university will establish courses and 
will grant degrees of D.P. — Doctor of Personology. 
They will be men and women trained to look at 
the whole functioning human being in his social sit- 
uation, with his economic difficulties, with his fam- 
ily obligations, with his personality- and individual 
peculiarities. Until such time as we do have doctors 
of personology, I believe that the physician — the 
medical men as a whole under the leadership of 
psychiatrists — must see to the leadership of the 
mental hygiene movement. And we want, increas- 
ingly, to feel that the public health workers of 
North America are with us, that they- understand 
the objectives and aims of psychiatry- as a highly 
specialized medical discipline, and mental hygiene 
as the lay movement symbolizing and focalizing the 
mental hygiene consciousness of the public at large.” 

Dr. Henry A. Luce, president of the Michigan 
State Medical Society and assistant professor of 
neurology and psy-chiatry at Wayne University, pre- 
sided at this session and introduced Dr. Sadler. 

“In every local area in Michigan there should be 
a whole-time health service — either on a city, county 
or district basis, manned by personnel trained and 
experienced in the art of health preservation,” de- 
clared Dr. Henry F. Vaughan, Detroit health com- 
missioner, who addressed the annual dinner meet- 
ing. “There exists in the medical and dental pro- 

67 



MICHIGAN’S DEPARTMENT OF HEALTH 


fessions a latent desire and ability to serve the pub- 
lic in health which must be activated and integrated 
into programs of community health service, both 
on a local basis and effectively interwoven with a 
state-wide health program.” 

Speaking on “Recent Progress in the National 
Campaign for the Control of Syphilis,” Assistant 
Surgeon General R. A. Vonderlehr declared that 
27 states now have a separate division or section 
of venereal disease control, and that 29 states have 
a full-time venereal disease control officer. He 
commended Michigan’s plan for the free distribu- 
tion of drugs for the treatment of syphilis and the 
provision of free laboratory diagnostic tests for 
syphilis for all persons. Eight other states besides 
Michigan have recently enacted laws requiring a 
serodiagnostic test for syphilis of applicants for 
marriage licenses, and three states, including New 
York, New Jersey and Rhode Island, have laws 
providing for the discovery and treatment of syphilis 
in pregnant women, Dr. Vonderlehr reported. 

Dr. Burton R. Corbus, president-elect of the 
Michigan State Medical Society, presided at the 
Thursday afternoon session. Dr. J. Orton Goodsell, 
president of the Michigan State Dental Society, also 
spoke at this session on “The Contribution of Oral 
Surgery to Public Health.” 

Dr. Gordon B. Myers, professor of medicine at 
Wayne University College of Medicine, discussed 
the use of antipneumococcic serums in Michigan’s 
pneumonia control program. The Michigan De- 
partment of Health is now supplying sera to phy- 
sicians for the treatment of Types I and II pneu- 
monia cases. Dr. Allan J. McLaughlin, of the Uni- 
versity of Michigan, outlined a basic program of 
sanitation, which, he said, must be built upon 
sound local foundations to succeed in state and 
nation. Advances in the production and use of 
pertussis vaccine were discussed by Dr. Pearl Ken- 
drick, associate director of Michigan Department 
of Health Laboratories. The epidemiology of the 
recent Shiga dysentery outbreak in Shiawassee 
county was explained by Dr. Berneta Block, staff 
physician of the Michigan Department of Health. 

At the annual luncheon business meeting of the 
Michigan Public Health Association, Dr. John L. 
Lavan, Grand Rapids health officer, was elected 
president of the association. Other officers include 
Dr. M. R. Kinde of the W. K. Kellogg Founda- 
tion, Battle Creek, vice president; Miss Marjorie 
Delavan, director, Bureau of Education, Michigan 
Department of Health, secretary-treasurer ; and Dr. 
Don W. Gudakunst, state health commissioner, rep- 
resentative on the governing council of the American 
Public Health Association. Dr. Kenneth R. Gibson 
of Detroit was elected to fill the vacancy on the 
board of directors. The association voted to hold 
its next annual meeting in Lansing. Resolutions 
were adopted honoring the memor}' of Dr. Richard 
M. Olin, former commissioner of the Michigan 
Department of Health, and Dr. U. G. Rickert, presi- 
dent of the State Council of Health, both of whom 
died during October. 


REGIONAL CONFERENCES OF 
HEALTH DEPARTMENTS 

Regional conferences of local health departments 
are being arranged by the Michigan Department of 
Health in cooperation with the full time health 
officers for the purpose of correlating the activities 
and improving the services of the state and local 
health departments. The conferences will be held 
once every two months in each of the various dis- 
tricts which have been organized on a regional basis. 

The first of the conferences was held December 7 
at Big Rapids with Dr. M. C. Igloe, director of 

68 


the Mecosta-Osceola Health Department, as host. 
The counties represented at this conference in- 
cluded Mecosta, Osceola, Clare, Gladwin, Arenac, 
Isabella, Midland and Bay. All staff members of 
these local health departments were invited to par- 
ticipate. Discussion topics and leaders were as fol- 
lows: venereal disease, Dr. R. S. Dixon; tubercu- 
losis, Dr. A. W. Newitt ; pneumonia, Dr. A. B. 
Mitchell ; and administrative problems, Dr. Don W. 
Gudakunst. 

The Northern Michigan Regional Health Con- 
ference was held December 14 with health depart- 
ment staffs from Kalkaska, Crawford, Missaukee, 
Roscommon, Wexford, Alcona, Iosco, Oscoda, Oge- 
maw, Alpena, Cheboygan, Montmorency, Presque 
Isle, Antrim, Charlevoix, Emmet and Otsego coun- 
ties participating. A conference of the Western 
Michigan departments, including Manistee, Mason, 
Lake, Oceana, Newaygo, Muskegon, Ottawa and 
Kent counties, has been scheduled for December 21. 
Conferences are also being arranged for the Upper 
Peninsula departments, the Eastern Michigan Dis- 
trict and the Southeastern Michigan District. 


STATE COUNCIL OF HEALTH MEETS 

Dr. Robert B. Harkness, director of the Barry 
County Health Department, was elected president 
of the State Council of Health at its advisory ses- 
sion with the state health commissioner in Lansing, 
November 23. Dr. Harkness succeeds Dr. U. G. 
Rickert of Ann Arbor, who died October 22. Dr. 
P. C. Lowery of Detroit, former president of the 
Michigan State Dental Society and vice president 
of the American Dental Association, has been ap- 
pointed a member of the Council to serve the unex- 
pired term of Dr. Rickert, which ends June 30, 
1941. Members of the Council discussed proposed 
changes in the department’s rules and regulations 
for the control of communicable diseases. Further 
consideration of this subject will be undertaken at a 
Council meeting scheduled for December 13. 


DR. BUCK TO REPORT SOON 

A series of preliminary reports to selected groups, 
based on a survey of Michigan’s state and local 
health services and needs, is being made by Dr. 
Carl E. Buck, field director of the American Public 
Health Association, who has been conducting the 
survey during the past six months. Dr. Buck’s 
final report is nearing completion and will be made 
public in the near future. Copies of the report 
and the recommendations of the survey committee 
will be made available to the officers of the Michi- 
gan State Medical Society. 


THE FIRST YEAR OF THE 
PREMARITAL EXAMINATION LAW 

Discussing the first year’s experience under the 
1937 Antenuptial Physical Examination Act before 
the annual Public Health Conference at Grand 
Rapids, Dr. W. J. V. Deacon, director of the Bu- 
reau of Records and Statistics, reported a decrease 
of 44 per cent in marriages during the early months 
of operation of the new law. 

“It was to be expected that marriages would 
decline in number during the early months of oper- 
ation of this act before the public became fully 
informed of its purposes and the details of its ad- 
ministration. During the first nine months of 1938 
while the marriage law was in operation, the Michi- 
gan Department of Health received reports of 20,- 
681 marriages. This compares with reports of 
37,242 marriages during the corresponding nine 
months of 1937 previous to the operation of the 
(Continued on page 70) 

Jour. M.S.M.S. 


ADVERTISING SECTION— M. S. M. S. 






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69 


CORRESPONDENCE 


law. The 1938 figures do not include the final re- 
turns from a few counties, but these returns would 
not significantly change the comparative figures. 

“To what extent this has been a loss is, of course, 
a matter for debate. Economic and social factors 
other than the new marriage law have a direct reac- 
tion upon the marriage rate and must be considered 
in explaining the decline in the early months of 
1938. To what extent this decline means fewer mar- 
riages of Michigan residents is a question, since it 
is true, no doubt, that many persons have gone to 
other states to be married. I have been glad to 
notice the reaction to this practice in some cases, 
however, as persons seem to lay themselves open to 
the criticism that they went out of the state to be 
married because they were afraid to take the physi- 
cal examination. It is also encouraging to note 
that marriages appear to be increasing in the later 
months of the year, indicating greater acceptance 
of the safeguards involved in the Michigan law. 

“The Michigan Department of Health laboratories 
have made 33,584 serological tests for syphilis for 
marriage license applicants. Of these, 405 were posi- 
tive for syphilis and 60 were doubtful, reported as 
plus-minus. The registered laboratories, which are 
authorized to make these tests, do not report the 
number of tests which they make but they did re- 
port 245 positive and 4 as doubtful. Thus, it appears 
that slightly more than 1 per cent of all applicants 
have shown positive indications of syphilis. 

“This means that through the operation of this 
law we have discovered 650 persons who could not 
be permitted to marry. If the operation of this 
law has uncovered 650 cases of syphilis it has been 
well worth while. Many of these cases claim that 
they had no knowledge of ever having had this dis- 
ease. Be this as it may, the fact remains that 650 
persons could not marry in this state because of 
syphilitic infection. Certainly this redounds to the 
benefit of the future generation, and if at least some 
of these cases were put under treatment, the gain is 
still greater.” 


MONTHLY MORTALITY REVIEW 

Mortality reports for the first ten months of 
1938, compiled by the Bureau of Records and Statis- 
tics, show a decline in total deaths from 44,819, in 
1937, to 41,707 this year. Infant mortality, too, is 
down from 3,673, in 1937, to 3,564, in 1938. Mater- 
nal deaths slightly exceed last year’s figures, when 
an all-time low rate for this cause was set, but 
with the current increase in births, the 1938 mater- 
nal mortality rate will compare favorably. There 
were 276 maternal deaths last year, compared to 291 
this year. Births have increased from 76,435, in 
1937, to this year’s total of 80,590 for the ten-month 
period. 

Comparative mortality figures for the major com- 
municable diseases, in 1937 and 1938, are indicated 
in the table below : 


Communicable Disease Mortality 
1937-1938 


Disease 

October, 

1938 

October, 

1937 

10 

Months, 

1938 

10 

Months, 

1937 

Pneumonia 


274 

2,271 

3,403 

Tuberculosis 

149 

160 

1,616 

1,816 

Typhoid Fever 

1 

2 

20 

25 

Diphtheria 

5 

12 

32 

57 

Whooping Cough... 

7 

9 

101 

114 

Scarlet Fever 

3 

8 

74 

132 

Measles 

0 

1 

96 

9 

Smallpox 

0 

0 

0 

1 

Meningitis 

2 

2 

18 

37 

Poliomyelitis 

1 

5 

8 

48 

Undulant Fever. . . . 

0 

0 

1 

o 

Syphilis 

40 

30 

318 

328 

Gonorrhea 

0 

0 

6 

7 


VENEREAL DISEASE CONTROL 
COURSE PLANNED 

The Michigan Department of Health is making 
arrangements for a course in venereal disease con- 
trol for health officers. Plans, as now contemplated, 
call for a week’s intensive instruction in the epi- 
demiological and clinical phases of venereal disease 
control. The course will be given twice to meet 
the convenience of all health officers. 


CORRESPONDENCE 


We received the following communication from 
Dr. J. R. McIntyre, secretary of the Michigan State 
Board of Registration in Medicine, Lansing. This 
interesting letter from the office of the attorney 
general of the state is self-explanatory. 

November 16, 1938 

Dear Doctor McIntyre : 

We have your letter of November 10 relative 
to an inquiry directed to your office as to the right 
of the medical personnel on the staff of hospitals 
operated by the United States in Michigan to prac- 
tice medicine. 

Section 8 of the Medical Practice Act, being 
Act 237, Public Acts of 1899, as amended, pro- 
vides, in part, as follows: 

“This act shall not apply to the commissioned 
surgeons of the United States army, navy or 
marine hospital service, in actual performance 
of their official duties ” 

It is our opinion that no Michigan license can 
be required of physicians employed by the "Federal 
government in Michigan whose practice is confined 
exclusively to the performance of their official 
duties. 

By being so exempt, however, such physicians are 
not thereby authorized to engage in other practice; 
and, should any such physician propose to engage 
in practice outside the scope of his official duties, 
he is required to be licensed by the Michigan State 
Board of Registration in Medicine, as any other 
physician. 

We trust the foregoing answers your question. 

Very truly yours, 

Raymond W. Starr 
Attorney General 
By John H. Brennan 
Deputy Attorney General 


IN MEMORIAM 


Dr. S. W. Woyt 

Dr. Stanley W. Woyt, a young physician of Jack- 
son, died suddenly as the result of an automobile 
accident, on November 23. A graduate of the 
Wayne University Medical School, class of 1930, 
Dr. Woyt spent his interneship in Fort Wayne, 
Indiana, practiced for a short time in Detroit, and 
in 1935 opened an office in Jackson. He is survived 
by his mother and sister. 


70 


Jour. M.S.M.S. 


ADVERTISING SECTION— M. S. M. S. 


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71 




<#> General News And Announcements 


100 Per Cent Club for 1939 

Menominee County Medical Society 
Muskegon County Medical Society 

The above county medical societies have 
paid 1939 dues for 100 per cent of their mem- 
ship. Dues for 1939 are $12.00 and are now 
payable. See your County Medical Society 
Secretary today and help make your Society 
100 per cent paid up for 1938. 


T. Y. Ho, M.D., of St. Johns was re-elected Sec- 
retary of the Clinton County Medical Society for the 
sixteenth consecutive time. 

* * * 

T. W. Thompson, M.D., of Traverse City, spoke 
on “Mental Health with Special Reference to Men- 
tal Hygiene,” at the annual meeting of the Alpena 
County Medical Society on December 18, in Alpena. 
* * * 

C. D. Brooks, M.D., Detroit, addressed the St. 
Clair County Medical Society at its meeting of 
December 13 on the subject of “Diagnostic Problems 
of Acute Abdominal Conditions.” 

* * * 

The International College of Surgeons will hold 
its Assembly in New York City on May 22, 23 and 
24, 1939. Edward Frankel, Jr., M.D., 217 East 17th 
St., New York, has been appointed General Chair- 
man. 

* * * 

Cyrus P. Sturgis, M.D., and Frank H. Bethell, 
M.D., of Ann Arbor, presented an illustrated lecture 
on “Anemias of Pregnancy” before the Hillsdale 
County Medical Society at its meeting of Decem- 
ber 8. 

* * * 

The Gratiot-Isabella-Clare County Medical So- 
ciety's meeting on December 15 was “Ladies’ Night.” 
All dentists, editors and hospital supervisors of the 
three counties were invited guests. The speaker 
of the evening was L. Fernald Foster, M.D., of 
Bay City. 

* * * 

Exhibit space at the 1939 Grand Rapids Conven- 
tion is being rapidly reserved. The Seventy-Fourth 
Annual Meeting will be held at the spacious Civic 
Auditorium which can adequately accommodate 
every phase of the Convention. The dates are 
September 18, 19, 20, 21 and 22, 1939. 

* * * 

The Wayne County Medical Society developed a 
clever “Inventory” which was distributed to its 
membership. The “Inventory” set forth in an at- 
tractive and interesting manner the scope of activi- 
ties of the Society and the services rendered to the 
individual members. 

* * * 

The Ottawa County Medical Society held its 
annual meeting in Holland on Thursday, December 
15. Members of the dental profession were invited 
guests. Councilor Vernor M. Moore of Grand 
Rapids and Secretary L. Fernald Foster of Bay 
City were guest speakers. 

72 


The American Medical Association has initiated 
a clip-sheet service. Each week the clip sheet, called 
“American Medical Association News,” containing 
several pages of official announcements, abstracts 
and condensations of original articles and editorials 
appearing in The Journal of the AMA and Hygiea, 
is sent to publishers. 

* * * 

A handbook of useful information for members 
is being developed by a special committee of the 
Wayne County Medical Society. It will include the 
Society s By-laws, committees, various rules and 
procedures, lists of clinics, diagnostic facilities, ap- 
proved hospitals and sanatoria, certain social agen- 
cies, synopses of laws regulating practice, and many 
other items of information useful to the practitioner. 

* * * 

G. H. Belote, M.D., of Ann Arbor, is guest 
speaker on the program of the International Post- 
Graduate Medical Assembly of Southwest Texas, 
which will be held in San Antonio on January 24, 
25, 26, 1939. Doctor Belote will deliver three lec- 
tures on (a) “Hormone Studies in Acne Vulgaris,” 
(b) “Modern Trends in the Treatment of Syphilis,” 
and (c) “Common Drug Eruptions.” 

* * * 

Recent articles by Michigan physicians in the 
Journal of the American Medical Association in- 
clude “Torsion of the Testicle” by John K. Ormond, 
M.D., Detroit, issue of November 19 ; “The Present 
Status of Ergonovine” by Ralph G. Smith, M.D., 
Ann Arbor, issue of December 10; and “Red Blood 
Cell Increase in Pernicious Anemia” by Raphael 
Isaacs, M.D., F. H. Bethell, M.D., M. C. Riddle, 
M.D., and Arnold Friedham, of Ann Arbor. 

* * * 

A Course in Anatomy will be given during the 
second semester, February 13 to May 30, 1939, one 
afternoon and evening each week, on Wednesday, 
1:00 — 10:00 P. M., by Professor Rollo E. McCot- 
ter. There will be an informal lecture the first 
part of the afternoon followed by dissection of the 
part under discussion. Fee $25. Graduate or post- 
graduate credit can be arranged. For further in- 
formation, address : Department of Postgraduate 

Medicine, University of Michigan, Ann Arbor, 
Michigan. 

* j|c 5}: 

Dr. Clarence A. Lightner, well known to many 
of the older members of the medical profession of 
the state, died on December 7, at his home in 
Tryon, N. C., at the age of seventy-seven. Mr. 
Lightner taught medical jurisprudence in the De- 
troit College of Medicine for many years. He was 
graduated from the University of Michigan in 1883 
and practiced law in Detroit. In 1892, he married 
Frances B. McGraw, daughter of Dr. Theodore A. 
McGraw, Senior, one of the best known surgeons of 
Detroit and Michigan in his day. 

* * * 

Many times a child is scolded for dullness when 
he should be treated for undernourishment. The 
scant fare of a “continental” breakfast provided in 
hundreds of homes may undernourish and leave the 
child listless, nervous or stupid at school. A solu- 
tion to this problem is Pablum, Mead’s Cereal, 
cooked and dried. It is six times richer than fluid 

Jour. M.S.M.S. 


GENERAL NEWS AND ANNOUNCEMENTS 


milk in calcium, ten times higher than spinach in 
iron, and abundant in vitamins Bi and G. Pablum 
furnishes protective factors needed by the school- 
child and is a valuable aid in increasing the weight. 
* * * 

The Radio Committee of the M.S.M.S., in collab- 
oration with the Joint Committee on Health Educa- 
tion, sponsored the following radio programs during 
the months of December and January': 

December 5. 1938 — “What Is a Goitre?” by Eugene 
Osius, M.D. 

December 12, 1938 — “Plastic Surgery,” by Claire Straith, 
M.D. 

December 19, 1938 — “Pneumonia,” by Alvin Price, M.D. 
December 26, 1938 — “Health and High Blood Pressure,” 
by Thomas McKean, M.D. 

January 9, 1939 — “Research in Medicine,” by Clifford 
Benson, M.D. 

jfc sje 

Ten more of your friends, who displayed their 
products and services at the 1938 Detroit Conven- 
tion last September. When you have an order, 
don’t forget your friends ! 

Holland-Rantos, Inc., New York, New York 
Horlick’s Malted Milk Corporation, Racine, Wisconsin 
The G. A. Ingram Company, Detroit, Michigan 
Jones Metabolism Equipment Company, Chicago, Illinois 
Jones Surgical Supply Company, Cleveland, Ohio 
A. Kuhlman & Company, Detroit, Michigan 
Lea & Febiger, Philadelphia, Pennsylvania 
Lederle Laboratories, Inc., New York, New York 
Libby, McNeill & Libby, Chicago, Illinois 
Liebel-Flarsheim Company, Cincinnati, Ohio 
* * * 

The Philadelphia County Medical Society desires 
to announce formally, the completion of its scien- 
tific program for the fourth annual postgraduate 
institute to be held in the Bellevue-Stratford Hotel, 
Philadelphia, during the week beginning March 
13th, 1939. The subjects to be considered are those 
embraced by the terms Blood Dyscrasias and Meta- 
bolic Disorders. These will be further subdivided 


for convenience in instruction into eighty-six clin- 
ical lectures, with open forum discussion for each 
topic, delivered by as many individual specialists of 
national distinction. 

* * * 

S. M. Keenan, a pioneer in the x-ra}' field in 
Detroit, died December 8. Mr. Keenan had been 
connected with the Eloise Hospital for more than 
forty years, during which time he acquired an ex- 
tensive collection of x-ray equipment, including 
tubes of the Crookes type to the very modern ap- 
paratus of the present time. Mr. Keenan was born 
in Brock, Ontario, in 1862, received his B.A. de- 
gree from the Detroit College in 1888, also his 
M.A. in 1896. He was an active member of many 
organizations, including the Michigan Academy of 
Science, the American Association for the Advance- 
ment of Science, the Detroit Roentgen Ray and 
Radium Society', and the Roentgen Ray Society. 

* * * 

Afflicted Child Commitments for month of No- 
vember, 1938 : 

Total cases, 1,746, of which 210 were sent to 
University Hospital and 1,536 were sent to mis- 
cellaneous local hospitals. From Wayne County, of 
the above, 24 went to University Hospital and 348 
went to local miscellaneous hospitals, total 372. 

Crippled Child: Total cases 305, of which 93 
were sent to University Hospital and 212 to miscel- 
laneous hospitals. From Wayne County, included 
in the above, 5 went to University Hospital and 47 
to miscellaneous hospitals, total of 52 cases. 

* * Jjc 

The American Board of Ophthalmology has an- 
nounced a change in method of examination of can- 
didates for the Board’s certificate. The examina- 
tion will be in two parts, the written examination 


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73 



GENERAL NEWS AND ANNOUNCEMENTS 



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to be given sixty days prior to the oral examination 
which will be given at the time and place of the 
meeting of the American Medical Association and 
of the American Academy of Ophthalmology and 
Oto-Laryngology. Candidates must pass the written 
examination before they may take the oral. The 
examinations scheduled for 1939 are Written, March 
15 and August 5, in various cities throughout the 
country ; and Oral, St. Louis, May 15, and in Chi- 
cago, October 6. Write John Green, M.D., 6830 
Waterman Ave., St. Louis, Mo., for application 
forms and further information. 

* * * 

New county medical society secretaries have been 
elected for 1939 as follows : 

E. S. Parmenter, M.D., Alpena, Secretary of the 
Alpena County Medical Society 

H. R. Mooi, M.D., Union City, Secretary of the 
Branch County Medical Society 

D. R. Smith, M.D., Iron Mountain, Secretary of 
the Dickinson-Iron County Medical Society 

F. L. S. Reynolds, M.D., Ironwood, Secretary of 
the Gogebic County Medical Society 

A. F. Litzenburger, M.D., Boyne City, Secretary 
of Northern Michigan Medical Society 

W. P. Petrie, M.D., Caro, Secretary of the Tus- 
cola County Medical Society 

* * * 

Laboratory studies and clinical investigations have 
shown that diphtheria and tetanus toxoids when 

given at the same time act independently and effec- 
tively in the production of their respective anti- 
toxins. The Eli Lilly Laboratories have devised a 
method of preparing in a single solution the com- 
bined alum precipitated toxoids. Two doses of 0.5 
c.c. given three to six months apart produce satis- 
factory immunity within six months after the last 
injection. If the person immunized should subse- 
quently receive an injury through which tetanus 

spores might enter the tissues, a stimulating dose 
of 0.5 c.c. tetanus alum precipated toxoid should be 
given. It is advantageous to have reasonable assur- 
ance of protection in a large percentage of im- 
munized cases and to be able to avoid serum sensi- 
tization from antitoxin administration, which should 
strongly commend tetanus immunization. 

* * * 

American Board of Obstetrics and Gynecology . — 
The general oral, clinical and pathological exami- 
nations for all candidates, Part II Examinations 
(Groups A and B), will be conducted by the entire 
Board, meeting in St. Louis, Missouri, on May 15 
and 16, 1939, immediately prior to the annual meet- 
ing of the Amereican Medical Association. Notice 
of time and place of these examinations will be 
forwarded to all candidates well in advance of the 
examination dates. 

Candidates for reexamination must request such 
reexamination by writing the Secretary’s Office be- 
fore the following dates: Part I — January 1, 1939; 
Part II — April 1, 1939. Candidates who are re- 
quired to take reexaminations must do so before 
the expiration of three years from the date of their 
first examination. 

Application for admission to Group A, May 1939, 
examination must be on file in the Secretary’s Office 
by March 15, 1939. 

Application blanks and booklets of information 
may be obtained from Dr. Paul Titus, Secretary, 
1015 Highland Building, Pittsburgh (6), Pennsyl- 
vania. 

^ ^ * 

A cancer center in Detroit was announced last 
month. Wayne University Medical School and a 
number of hospitals, notably Receiving, Grace and 
Woman’s Hospitals, will give clinical training in 
diagnosis and treatment of malignancies. The 

Jour. M.S.M.S. 


74 



GENERAL NEWS AND ANNOUNCEMENTS 


announcement was made by Dr. Ludvig Hektoen of 
the United States Public Health Service. The work 
will be open to graduate physicians who are inter- 
ested in cancer specialization. A three-year train- 
ing period at these hospitals is announced. Ap- 
pointments for training will be made by the United 
States surgeon-general from nominations made by 
the national cancer advisory council. The fol- 
lowing local men are named as instructors : Dr. 

Edgar H. Norris, professor of pathology at Wayne 
University, and Dr. Osborn Brines, Assistant Pro- 
fessor at Wayne University Medical School, will 
teach pathology; Dr. Rollin Stevens and Dr. Clar- 
ence I. Owen of Grace Hospital and Dr. Harry 
Nelson, professor and director of the hospital tumor 
clinic, and Dr. Frances A. Ford of the Woman’s 
Hospital have been appointed instructors. Dr. 
Charles G. Johnston, professor of surgery of the 
Wayne University Medical School, will deal with 
the subject of general surgical experience at Re- 
ceiving Hospital. 

if; % 

Of Interest to 
the Ophthalmologist 

The amount of eye material in any one institution 
is small. It is hoped by pooling this material from 
many hospitals to build up a collection of patholog- 
ical eye material. Properly prepared and diagnosed 
this will enable Pathologists and Ophthalmologists 
in this part of the country to advance their knowl- 
edge of ocular pathology to an extent which has 
hitherto not been possible. 

It is proposed to keep on permanent file in the 
ophthalmic research laboratory of Wayne University 
Medical School, available for study by Ophthalmol- 
ogists and Pathologists, an adequate number of 
slides, together with the unused portions of the 
specimens, and cross-indexed data obtained from the 
case history and from the report of the specimen. 
Sample slides and a copy of this laboratory’s report 
in duplicate will be returned to the source of the ma- 
terial. The Pathologist can confirm diagnosis and 
make his report in the usual way. If the block is 
desired or if additional slides are wanted, this will 
ordinarily be possible if requested. 

The Pathologists and Ophthalmologists of Hospi- 
tals interested in this free service on ophthalmic 
material may communicate with the Ophthalmic Re- 
search Laboratory, Wayne University, College of 
Medicine, 1512 St. Antoine St., Detroit. 

* * * 

The Madge Sibley Hoobler Home 

The Madge Sibley Hoobler Home, located at 
25300 W. McNichols Road in Detroit, stands as a 
memorial to the late Mrs. Hoobler, wife of Dr. 
Raymond B. Hoobler, Detroit pediatrician, well 
known to the profession in Michigan. The Madge 
Sibley Hoobler Home is a guest house for con- 
valescent girls. It was proposed by the late Mrs. 
Hoobler, who died over two years ago. The 
Hoobler Home can accommodate twenty-five guests, 
who may spend as long as two weeks, without 
expense, in an atmosphere of quiet refinement and 
healthy living. The house is organized as a non- 
profit corporation. On its Women’s Board of Di- 
rectors are Miss Charlotte Waddell, chairman, su- 
perintendent of Women’s Hospital ; Miss Walker ; 
Mrs. H. R. Crowell, of First Presbyterian Church, 
in charge of religious and social activities ; Mrs. 
W. B. Cooksey, head of the Detroit Girl Scouts 
and in charge of outdoor activity; Mrs. Josephine 
Powers; Mrs. Allen B. Crow; and Mrs. Icie Macy 
Hoobler, Dr. Hoobler’s wife. 

On the advisory board are William J. Norton, 
chairman, head of the Michigan Children’s Fund ; 
Clarence W. Wilcox, attorney for the fund ; Stew- 

January, 1939 


Cook County 

Graduate School of Medicine 

(In affiliation with COOK COUNTY HOSPITAL) 
Incorporated not for profit 

ANNOUNCES CONTINUOUS COURSES 

MEDICINE — Personal Courses and Informal Course 
starting every week. Two Weeks Course in Internal 
Medicine starting June 5, 1939. 

SURGERY — General Courses One, Two, Three and Six 
Months; Two Weeks Intensive Course in Surgical 
Technique with practice on living tissue; Clinical 
Courses; Special Courses. Courses start every Monday. 

GYNECOLOGY — Two Weeks Course starting February 
27, 1939. Clinical and Personal Courses starting every 
week. 

OBSTETRICS — Two Weeks Intensive Course starting 
March 13, 1939. Informal Course starting every week. 

FRACTURES & TRAUMATIC SURGERY— Informal 
Course every week; Intensive Ten Day Course start- 
ing February 13, 1939. 

OTOLARYNGOLOGY — Two Weeks Intensive Course 
starting April 10, 1939. Informal Course starting 

every week. 

OPHTHALMOLOGY — Two Weeks Intensive Course 
starting April 24, 1939. Informal Course starting every 
week. 

CYSTOSCOPY — Ten Day Practical Course rotary every 
two weeks. 

GENERAL, INTENSIVE AND SPECIAL COURSES 
IN ALL BRANCHES OF MEDICINE, SURGERY 
AND THE SPECIALTIES 

TEACHING FACULTY — Attending Staff 
of Cook County Hospital 

ADDRESS: 

Registrar, 427 South Honore Street, Chicago, I1L 


Laboratory Apparatus 

Coors Porcelain 
Pyrex Glassware 
R. & B. Calibrated Ware 
Chemical Thermometers 
Hydrometers 
Sphygmomanometers 


J. J. Baker & Co., C. P. Chemicals 
Stains and Reagents 
Standard Solutions 


Biologicals 

Serums Vaccines 

Antitoxins Media 

Bacterins Pollens 


We are completely equipped and solicit 
your inquiry for these lines as well as for 
Pharmaceuticals, Chemicals and Supplies, 
Surgical Instruments and Dressings. 

The Rupp and Bowman Co. 

319 Superior St. Toledo, Ohio 


75 



GENERAL NEWS AND ANNOUNCEMENTS 



WAUKESHA SPRINGS SANITARIUM 


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For the Care and Treatment of 
Nervous Diseases 


Building Absolutely Fireproof 


BYRON M. CAPLES, M. D., Medical Director 

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Tissue Diagnosis 

The Wassermann and Kahn Tests 

Blood Chemistry 

Bacteriology and Clinical Pathology 

Basal Metabolism 

Aschheim-Zondek Pregnancy Test 

Intravenous Therapy with rest rooms for 
Patients. 

Electrocardiograms 


Central Laboratory 

Oliver W. Lohr, M.D., Director 

537 Millard St. 

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Phone, Dial 2-3893 

The pathologist in direction is recognized 
by the Council on Medical Education 
and Hospitals of the A. M. A. 


art Hamilton, superintendent of Harper Hospital ; 
L. A. Ewald, A. B. Hoskin, and Dr. W. B. Cooksey 
of the Harper staff. The guest house staff includes 
Mrs. Norma Seibert, director; Miss Dorothy Wad- 
dell, Mrs. Sue Wicher and Dr. Fanny Kenyon. 

* * * 

Forum on Allergy 

Physicians interested in allergy are invited to at- 
tend the North Central Forum on Allergy to be 
held at the Commodore Perry Hotel, Toledo, Sun- 
day, January 15. 

The meeting will open with an informal “get-to- 
gether” Saturday evening, January 14, at the Com- 
modore Perry Hotel. Physicians planning to attend 
the Forum are urged to arrive in time for this 
social session which may be the high-light of the 
meeting. 

The program for the two sessions, Sunday, Jan- 
uary 15, follows : 

Morning Session, 10:00 A. M. 

1. Food Allergy 

“Diagnostic Measures,” by Dr. Samuel M. 
Feinberg, Chicago ; discussants, Dr. M. A. 
Weitz, Cleveland, and Dr. Sam Levine, Detroit. 

“Value of Skin Tests in Diagnosis of Food 
Allergy,” by Dr. George Waldbott, Detroit; 
discussants, Dr. Albert Zoss, Cincinnati, and 
Dr. I. M. Hinnant, Cleveland. 

“Dietary Management of Food Allergy,” by 
Dr. Jonathan Forman, Columbus; discussants, 
Dr. David M. Cowie, Ann Arbor, and Dr. 
George L. Lambright, Cleveland. 

2. “Drug Hypersensitivity,” by Dr. John H. Mitch- 

ell, Columbus ; discussants, Dr. Barney Cre- 
dille, Flint, and Dr. Frank Menagh, Detroit. 

Luncheon — Crystal Room, Commodore Perry 
Hotel. 

Afternoon Session, 2:00 P. M. 

“Preparation of Protein Extracts,” by Dr. Mil- 
ton B. Cohen, Cleveland ; discussants, Dr. 
Leon Unger and Dr. Tell Nelson, Chicago. 

“Preparation of Plant Oil Extracts for Diag- 
nosis and Treatment,” by Dr. L. E. Sevier, 
Dayton; discussants, Dr. John Sheldon, Ann 
Arbor, and Dr. Wm. P. Carver, Cleveland. 

(Papers, limited to ten minutes each; discussants limited 
to five minutes.) 

This meeting was planned to foster acquaintance 
and exchange of ideas of members of the Cleve- 
land, Chicago, Michigan and Ohio Valley Society 
of Allergists. However, any physicians, in good 
professional standing, who are interested in allergy 
are most welcome. 

Further information can be obtained by address- 
ing Dr. Karl D. Figley, 316 Michigan Street. To- 
ledo, Ohio. 

* * * 

Dr. Vaughan Honored 

Dr. Henry F. V aughan will have completed twen- 
ty-five years of service with the Detroit Depart- 
ment of Health on January first. 

Dr. Vaughan was born in Ann Arbor, on October 
12, 1889, the son of Dr. and Mrs. Victor C. Vaughan. 
He received his primary and high school edu- 
cation in Ann Arbor, followed by a year at 
Chateau de Lancy, at Geneva, Switzerland, before 
entering the University of Michigan, from which he 
received three degrees, Bachelor of Science in 
engineering in 1912, M.S. in the same field in 1913 
and Doctor of Public Health in 1915. 

He was Assistant Sanitary Engineer for the 
Michigan Department of Health from 1913 to 1914 
and in 1914 he came to the Detroit Department of 
Health as Sanitary Engineer and Assistant Health 
Officer. When the United States went into the. war 
he became a captain in the sanitary corps of the 
(Continued on page 78) 

Jour. M.S.M.S. 


76 




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January, 1939 


77 



GENERAL NEWS AND ANNOUNCEMENTS 


United States army and was released to become 
Commissioner of Health in 1918. He has been 
president of the American Public Health Associa- 
tion, and has served for many years on the Gov- 
erning Council of that organization. Since 1915, 
he has been associate professor of public health at 
Wayne University, and since 1921 special lecturer 
at the University of Michigan. 

He is an associate member of the Wayne County 
Medical Society and an honorary member of the 
Detroit District Dental Society. He has contributed 
many articles on public health and is joint author, 
with his father and Dr. George T. Palmer, of 
“Epidemiology in Public Health.” 

Physicians throughout the country have learned 
to respect Dr. Vaughan for his appreciation of the 
part played by the private practitioner of medicine 
in promoting public health. His cooperative plan 
with the Wayne County Medical Society, which has 
been entitled “Medical Participation in Public 
Health,” has been watched and adopted in an in- 
creasing number of localities. 

On Thursday evening, January twelfth, at 7 :00 
o’clock, the staff of the Detroit Department of 
Health will honor Dr. Vaughan at a subscription din- 
ner, to which physicians in Detroit are invited. 
Tickets may be obtained from the executive offices 
of the Wayne County Medical Society or the office 
of the secretary of the Department of Health. 

* * * 

CREDIT IS DUE 

The following members of the Michigan State 
Medical Society were present at the postgraduate 
assemblies of the Michigan State Medical Society 
Annual Meeting, Detroit, September 19, 20, 21, 22, 


1938. 

Agnelly, Ed. J. — Detroit 
Allen, R. C.— St. Joseph 
Amberg, Emil — Detroit 
Andrew, F. T. — Kalamazoo 
Andries, R. C. — Detroit 
Appel, Philip R. — Detroit 
Arnold, A. L., Jr. — Owosso 

Badgley, C. E. — Ann Arbor 
Bailey, Louis J. — Detroit 
Baker, H. B.— Detroit _ 
Bakst, Joseph A. — Detroit 
Balser, Chas. W. — Detroit 
Barnett, S. E. — Detroit 
Barnes, Donald J. — Detroit 
Barrett, Joseph E. — Lansing 
Barrett, W. D. — Detroit 
Barstow, W. E. — St. Louis 
Barton, J. R. — Detroit 
Bates, Gaylord S. — Detroit 
Beck, Otto S. — Birmingham 
Becker, Myron G. — Edmore 
Biegler, Sydney K. — Detroit 
Bell, William M. — Detroit 
Benning, C. H. — Roval Oak 
Berman, Harry S. — Detroit 
Bernstein, A. E. — Detroit 
Best, H. M. — Lapeer 
Bicknell, N. J. — -Detroit 
Biddle, Andrew P. — Detroit 
Blaess, Marvin J. — Detroit 
Blain, A. W. — Detroit 
Blanchard, F. N. — Detroit 
Boyd, D. R. — Muskegon 
Bradley, J. B. — Eaton 
Rapids 

Braley, W. N.- — Detroit 
Brasie, Donald R. — Flint 
Brisbois, H. J. — Plymouth 
Brook, J. D. — Grand Rapids 
Brown, Henry S. — Detroit 
Brown, I. W. — Kalamazoo 
Bruehl, Richard A. — Detroit 
Brunk, A. S,— -Detroit 
Brunk, C. F. — Detroit 
Brunson, E. T. — Ganges 
Budler, Samuel A. — Pontiac 
Budson, Daniel — Detroit 
Buesser, Fred G. — Detroit 
Burch, L. J. — Mt. Pleasant 
Burley, J. H. — -Port Huron 
Byington, G. M.— Detroit 

Caldwell, J. Ewart — Detroit 
Carlucci, Peter F. — Detroit 


Carstens, Henry R. — Detroit 
Caster, E. W. — Mt. Clemens 
Catherwood, A. E.— -Detroit 
Chase, A. W. — Adrian 
Cheney, G. C. — Detroit _ 
Christian, L. G. — Lansing 
Christopoulos, D. G. — 
Detroit 

Clark, Harold E. — Detroit 
Clark, Harry L. — Detroit 
Clarke, George L. — Detroit 
Clinton, Wm. R. — Detroit 
Cole, Fred H. — Detroit 
Conrad, G. A. — Sault Ste. 
Marie 

Cook, Henry — Flint 
Cooksey, W. B. — Detroit 
Cooper, James B. — Detroit 
Corbus, Burton R. — Grand 
Rapids 

Cree, Walter J. — Detroit 
Cruikshank, Alex. — Detroit 
Cummings, H. H. — 

Ann Arbor 

Curhan, Joseph H. — Detroit 

D’Alcorn, E. — Muskegon 
Danforth, M. E. — Detroit 
Davis, C. R.- — Detroit 
Day, Luther W. — Jonesville 
Defnet, Wm. A. — Detroit 
DeGurse, T. E.— Marine 
City 

Dempster, J. H. — Detroit 
Denman, Dean C. — Monroe 
DeVries, C. F. — Lansing 
Dibble, Harry F. — Detroit 
Donald, Douglas- — Detroit 
Doyle, Fred M. — Kalamazoo 
Doyle, George H. — Detroit 
Dubpernell, M. S. — Detroit 
Dunn, Cornelius — Detroit 
Dutchess, Chas. E. — Detroit 

Ellet, Wm. C. — Benton 
Harbor 

Fenech, Harold B. — Detroit 
Fenton, Edw. H. — Detroit 
Finch, Russell L. — Lansing 
Fisher, -G. F.- — Hastings 
Fitzgerald, E. W. — Detroit 
Folsome, C. E. — Ann Arbor 
Forbes, Edwin B. — Detroit 
Forrester, A. V. — Detroit 


Foster, L. F. — Bay City 
Foster, Owen C. — Detroit 
Foss, Edwin O. — Muskegon 
Fralick, F. B. — Ann Arbor 
Frazer, Mary M. — Detroit 
Freese, John A. — Detroit 
Friedlaender, B. — Detroit 
Fyvie, J. H. — Manistique 

Garner, Howard B. — Detroit 
Geib, L. O. — Detroit 
Gelber, S. — Detroit 
Gellert, I. S. — Detroit 
Gonne, Wm. S. — Detroit 
Gordon, W. H. — Detroit 
Gould, S. E. — Detroit 
Grant, L. E. — Detroit 
Greene, I. W. — Owosso 
Grossman, S. C. — Detroit 
Gruber, T. K. — Eloise 

Hackett, Walter L. — Detroit 
Hafford, A. L. — Albion 
Hafford, George C. — Albion 
Hall, James A. J. — Detroit 
Hansen, H. C. — Battle 
Creek 

Harkness, R. B.- — Hastings 
Harm, W. B. — Detroit 
Harrison, Henry — Detroit 
Hart, C. D. — Newberry 
Hart, Dean W. — St. Johns 
Hartman, F. V. — Detroit 
Harvie, L. C. — Saginaw 
Hasley, C. K. — Detroit 
Hasner, R. B. — Royal Oak 
Haughey, W. — Battle Creek 
Heavenrich, T. F. — Port 
Huron 

Henderson, L. T. — Detroit 
Hewitt, Leland V. — Detroit 
Hirschman, L. J. — Detroit 
Hodge, James B. — Detroit 
Hoffman, T. E. — Vassar 
Hoffmann, M. H. — Eloise 
Holly, L. E. — Muskegon 
Holmes, R. H. — Muskegon 
Hookey, J. A. — Detroit 
Howlett, R. R. — Caro 
Hubbell, R. J. — Kalamazoo 
Huntington, H. G. — Howell 

Imthun, E. — Grand Ledge 
Insley, Stanley W. — Detroit 
Isaacs, J. C. — Detroit 
Isaacson, Arthur — Detroit 

Jackson, C. C. — Imlay City 
Jamieson, D. A. — Arcadia 
Jamieson, R. C. — Detroit 
Jonikaitis, J. — Detroit 
Johnson, L. J. — Ann Arbor 
Johnston, E. V. — Detroit 
Johnstone, Ben I. — Detroit 

Kay, Harry H.— Detroit 
Keane, William E. — Detroit 
Kelsey, Lee — Lakeview 
Kennedy, Wm. Y. — Detroit 
Keyport, C. R. — Grayling 
Kilroy, J. Frank — Detroit 
Kirschbaum, Harry — Detroit 
Kirton, J. R. W. — Calumet 
Klein, William — Detroit 
Kleinmam S. — Detroit 
Kliger, David- — Detroit 
Kniskern, Paul W. — Grand 
Rapids 

Krebs, Wm. T. — Detroit 

Laird, R. Lee — Detroit 
Lampman, H. H. — Detroit 
Lang, W. W. — Kalamazoo 
Lawrence, Wm. C. — Detroit 
Ledwidge, P. L. — Detroit 
Lemen, C. E. — Traverse City 
LeMire, W. A. — Escanaba 
Lemmon, C. E. — Detroit 
Lewis, Lee A. — Manistee 
Libby, E. M. D. — Iron River 
Lipkin, Ezra — Detroit 
Lippold, Paul H. — Detroit 
Livingston, G. M. — Detroit 
Loupee, S. L.— Dowagiac 
Luce, Henry A. — Detroit 

Marshall, W. H. — Flint _ 
McAlpine, A. E. — Detroit 
McCall, J. H. — Lake City 
McClellan, G. L. — Detroit 
McDonald, Allan — Detroit 
McIntyre, J. Earl — Lansing 
McKean, R. M. — Detroit 
Manthei, W. A. — Lake 
Linden 


Mason, Elta — Flint 
Menzies, Clifford G. — Iron 
Mountain 

Mercer, C. M. — Battle 
Creek 

Merritt, Edwin D. — Detroit 
Mertaugh, W. F. — Sault Ste. 
Marie 

Miller, Harold A. — Lansing 
Miller, J. D. — Grand Rapids 
Mishelevich„Sophie — Detroit 
Moisides, V. P.— Detroit 
Moore, Vernor M. — Grand 
Rapids 

Morris, Harold L.- — Detroit 
Murphy, Frank J. — Detroit 

Neumann, A. J. — Detroit 
N ovy, R. L. — Detroit 

Oakes, Ellery A. — Manistee 
O’Brien, D. J. — Lapeer 
O’Donnell, F. J. — Alpena 
Olson, Richard E. — Pontiac 
O’Meara, James J. — Jackson 
Osius. Eugene A. — Detroit 
Osterlin, Max F. — Traverse 
City 

Parmelee, G. H.— Detroit 
Pauli, Chester A.- — Detroit 
Pearse, Harry A. — Detroit 
Peirce, Howard W. — Detroit 
Penberthy, G. C. — Detroit 
Perkins, Roy C. — Bay City 
Pickard, O. W. — Detroit 
Pierce, Frank L. — Detroit 
Pinkus, Hermann — Detroit 
Pino, Ralph H. — Detroit 
Place, Edwin H. — Midland 
Plaggemeyer, H. W. — 
Detroit 

Potts, Enos A. — Detroit 
Prendergast, J. J. — Detroit 
Priborsky, B. H.— Detroit 

Randall, H. E.- — Flint 
Reveno, Wm. S. — Detroit 
Richardson, K. R. — Detroit 
Riker, A. D. — Pontiac 
Riley, Philip A. — Jackson 
Robb, J. M. — Detroit 
Robb, Herbert F. — Belleville 
Robinson, R. G. — Detroit 
Rosen, Robert — Detroit 
Rubright, L. W. — Detroit 
Rupp, Jacob Roth — Detroit 
Russell, T. P. — Centerline 

Sadi, Lufti M. — Detroit 
Sage, E. O. — Detroit 
Saltonstall,. Gilbert B. — 
Charlevoix 

Salot, R. F. — Mt. Clemens 
Sawyer, Harold F. — Detroit 
Scher, J. N. — Mt. Clemens 
Schreiber, Frederic — Detroit 
Scrafford, R. E. — Bav City 
Scott, Dwight F. — Sault 
Ste. Marie 

Scott, Robt. D.— Flint 
Segar, Laurence F. — Detroit 
Seibert, A. H.— -Detroit 
Selmon, B. L. — Battle Creek 
Sethney, H. T.- — Menominee 
Shafarman, E. M.— Detroit 
Shaffer, Loren W. — Detroit 
Shawan, H. K. — Detroit 
Sheldon, Suel A.- — Saginaw 
Sherman, B. B. — Detroit 
Sherman, Geo. A.- — Pontiac 
Sherwood, D. L. — Detroit 
Shulak, Irving B.— Detroit 
Simpson, C. E. — Detroit 
Skully, G. A. — Detroit 
Sladek, E. F. Traverse 
City 

Slevin, John G. — Detroit 
Small, Henry — Detroit 
Smeck, A. R.. — Detroit 
Smith, D. R.- — Iron 
Mountain 

Smith, W. Joe — Cadillac 
Snapp, Carl F. — Grand 
Rapids 

Souda, Andrew — Wyandotte 
Southwick, G. Howard — 
Grand Rapids 
Southwick, S. W. — Detroit 
Spalding, Edw. D. — Detroit 
Spears, M. L. — Pontiac 
Spinks, R. E. — Newberry 
Springer, R. A. — Centerville 
Stapleton, Wm. J. — Detroit 
Stern, Louis D. — Detroit 

Tour. M.S.M.S. 


78 


GENERAL NEWS AND ANNOUNCEMENTS 


Stickley, A. E. — Coopersville 
Straith, Claire L. — Detroit 
Strong, W. F. — Ontonagon 
Stryker, O. D. — Frefaont 
Sugar, David I. — Detroit 
Sutton, P. E. — Royal Oak 

Tatelis, G. A.— Detroit 
Thompson, Alvin — Flint 
Torgerson, Wm. R. — Grand 
Rapids 

Toshach, Clarence — Saginaw 
Tuck, R. G. — Pontiac 

Umphrev, C. E. — Detroit 
Urmstori, P. R. — Bay City 

Valade, Cyril K. — Detroit 
Vale, C. Fremont — Detroit 
Vandeventer, V. H. — 
Ishpeming 

VanEhee, Geo. H. — Detroit 
Vaughan, Henry F. — Detroit 
Vonder Heide, E. C. — 
Detroit 


Wade, R. L. — Coldwater 
Waldie, Geo. M. — Hancock 
Walker, Roger V. — Detroit 
Ward, William T. — Detroit 
Weber, Karl W. — Detroit 
Webster, J. C. — Marlette 
Weller, C. N. — Detroit 
Wenger, A. V. — Grand 
Rapids 

Wessinger, John A. — Ann 
Arbor 

Wiley, Harold W. — Lansing 
Willison. Clayton— Sault 
Ste. Marie 

Wishropp, Edw. A. — Detroit 
Wittenberg, Samson S. — 
Detroit 

Witwer, E. R. — Detroit 
Woodworth, W. P. — Detroit 

Yeo, G. H. — Big Rapids 
Yates, H. W. — Detroit 
Yeomans, T. G. — St. Joseph 

Zindler, George A. — Detroit 


The above list represents the registration of Mon- 
day, September 19, 1938. The registration of Tues- 
day, Wednesday, and Thursday will be published in 
succeeding issues of The Journal. 


Abstracts in the Field of Physical Therapy 

Blackman, W. W., and Richardson, J. L. : Diathermy 
in Coronary Thrombosis. Arch. Physical Ther., 
21:412 (July), 1938. 

Short wave diathermy is the most efficient and 
reliable agent available for improving the blood sup-, 
ply to the myocardium in coronary thrombosis. Clin- 
ical and electrocardiographic evidence shows that 
short wave diathermy through the region of the 
heart allays arterial spasm, induces coronary dilata- 
tion and develops new blood pathways. 



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Hansel, F. K. : Status of Ionization in Nasal Allergy*. 

Arch. Phys. Ther., 21 :489, (August) 1938. 

According to leading rhinologists, ionization of 
the nasal mucosa is safe and satisfactory in the 
treatment of hay fever and nasal allergy. According 
to observation of leading allergists, ionization does 
not give results comparable to those obtained by 
allergic methods of treatment. A few rhinologists 
have reported results from escharotics equally as 
satisfactory as those obtained by ionization. It is 
generally concluded that ionization in nasal allergy- 
should be confined to those cases in which allergic 
methods of treatment have failed to give satisfac- 
tory relief of symptoms. The selection of cases for 
this type of treatment, therefore, should be made 
by the close cooperation of the allergist and the 
rhinologist, or by the rhinologist adequately familiar 
yvith the practice of allergy. 


Osborne, S. L., Blatt, M. L., and Neymann, C. A. : 
Electropyrexia in Rheumatic Carditis, Chorea and 
other Childhood Diseases. Physio-Therapy- Rey r . 
18:68, (March-April) 1938. 

The authors treated twenty-five patients suffering 
from chorea minor, seven of yvhom had rheu- 
matic carditis. The authors feel that fey^er is 

not contraindicated yvhere a heart lesion is present 
because all the patients yvere poorly nourished and 
poor risks and had nothing happen to them from the 
fever treatments. Treatment is carried out in 8 
hour sessions at a temperature about 104 F. Rheu- 
matic carditis. The authors feel that fever is 
benefited by artificial fever therapy. The chorei- 
form moy^ements of Sydenham’s chorea cease in 88 
per cent of the cases treated. The movements stop 
after an average of four sessions, which justifies 
the belief that the disease is aborted and will not 
recur. 


Behind 

Mercurochrome 

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is a background of 

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Controlled laboratory investigation 

Chemical and biological control of 
each lot produced 

Extensive clinical application 

Thirteen years’ acceptance by the 
Council of Pharmacy and Chem- 
istry of the American Medical 
Association 

A booklet summarizing the impor- 
tant reports on Mercurochrome and 
describing its various uses will be 
sent to physicians on request. 

Hynson, Westcott & Dunning, Inc. 

BALTIMORE, MARYLAND 




January, 1939 


79 




THE DOCTOR’S LIBRARY 


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Acknowledgment of all books received will be made in 
this column and this will be deemed by us a full com- 
pensation to those sending them. A selection will be 
made for review, as expedient. 


SPINAL ANESTHESIA. By Louis H. Maxson, A.B., M.D. 
Practicing specialist in anesthetics, formerly Chief 
Anesthetist, Harborview Hospital, Seattle, Washington, 
with a foreword by W. Wayne Babcock, M.D., LL.D., 
F.A.C.S., Professor of Surgery, Temple University School 
of Medicine, with illustrations. Philadelphia and New 
York: J. B. Lippincott Company, 1938. 

“The dangers of spinal anesthesia lie with the 
user, more than with the drug,” writes Dr. Wayne 
Babcock, as a preface to a plea for skill on the 
part of the spinal anesthetist. This work of over 
400 pages discusses every phase of the subject of 
spinal anesthesia, including anatomical considerations, 
physical factors, drugs, technical considerations, 
special technic and technical difficulties, dangers, 
complications, advantages and disadvantages. 


DISEASES OF THE NOSE, THROAT AND EAR. By 
W. Wallace Morrison, M.D. Clinical Professor and 
Chief of Clinic, Department of Otolaryngology, New York 
Polyclinic Medical School and Hospital, illustrated. Phil- 
adelphia and London: W. B. Saunders Company, 1938. 

This work is based upon fifteen years of teaching 
the subject of otolaryngology' to postgraduate stu- 
dents. This fact should recommend it to the gen- 
eral practitioner as well as the specialist, for, while 
otolarynogolgy is a specialty, there are certain 
phases, particularly the acute stages, which the 
general practitioner should understand. The work 
is well illustrated by pen drawings and zinc etchings, 
evidently made to illustrate the particular subject 
under discussion. The usual method is followed, 
namely, of prefacing the subject with full descrip- 
tion of anatomy and physiology. The work can be 
heartily' recommended. 


MARIHUANA, AMERICA’S NEW DRUG PROBLEM. 
By Robert R. Walton, Professor of Pharmacology, School 
of Medicine, University of Mississippi, with a foreword 
by E. M. K. Ceiling, Professor of Pharmacology, Uni- 
versity of Chicago, and a chapter by Frank R. Gomila. 
Commissioner of Public Safety, New Orleans, and M. C. 
Gomila Lambou, Assistant City Chemist. Philadelphia: 
J. B. Lippincott Company, 1938. Price $3.00'. 

This little work of 223 pages will doubtless supply- 
all the information on the subject that anyone may 
desire. The authors are exceedingly well oualified 
by position and training to write authoritatively on 
the subject. 


ENDOCRINE THERAPY IN GENERAL PRACTICE. 
By Elmer L. Sevringhaus, M.D., F.A.C.P. Professor 
of Medicine, University of Wisconsin, Madison, Wis- 
consin ; Editor, Department of Endocrinology, The Year 
Book of Neurology, Psychiatry & Endocrinology, Chi- 
cago: The Year Book Publishers, Inc., 1938. 

This is a much abridged treatise on the use of 
some of the known, effective secretions of the en- 
docrine glands that are available. Since this is a 
work designed for the general practitioner, much 
of the knowledge concerning these glands has been 
reserved for more complete works on this subject. 
Even those general practitioners who desire to do 
intelligent work in this field will find it to their 
advantage to refer to the works which more com- 
pletely cover the subject. 


A TEXTBOOK OF BACTERIOLOGY. Thurman B. Rice, 
A.M., M.D., Professor of Bacteriology and Public Health 
at the Indiana University School of Medicine. Second 
Edition, Revised. 563 pages with 121 illustrations. Phila- 
delphia and London: W. B. Saunders Company, 1938. 
Cloth, $5.00 net. 

As in previous editions, the author has attempted 
to make this work a text for students and practi- 

Jour. M.S.M.S. 


80 


THE DOCTOR’S LIBRARY 


tioners. He has designed it as an aid for the in- 
terpretation of disease, rather than a book for the 
identification of bacteria. He has held the descrip- 
tions of the morphology and the cultural character- 
istics of bacteria to the essentials, leaving detailed 
information for more voluminous works. Such 
newer subjects as the typing of pneumococci, the 
use of sulphanilamide, and of tetanus alum-toxoid 
are included in this work. 

The book appeals to the practitioner as a val- 
uable addition to his reference library. 


THE 1938 YEARBOOK OF GENERAL MEDICINE. 
Edited by George F. Dick, M.D., J. Burns Amberson, 
Jr., M.D., George R. Minot, M.D., S.D., F.R.C.P. 
(Hon.) Edin., William B. Castle, M.D., A.M., M.D. 
(Hon.) Utrecht, William D. Stroud., M.D., George B. 
Eusterman, M.D. Chicago: The Year Book Publishers, 
Inc., 1938. 

The Year Book Series in the various departments 
of medicine and surgery have won for themselves a 
unique place in the estimation of the medical pro- 
fession. The science of medicine in all its branches 
progresses so rapidly that a sifting of values each 
year is a necessity. When this is done by out- 
standing authorities in the various subjects, the 
product is of inestimable worth. The above men- 
tioned names as authors should commend the 1938 
Yearbook to every internist and general practitioner. 
The work comprises 840 pages of reading matter 
with 178 illustrations in the way of halftones and 
charts. This work cannot be too highly recom- 
mended as a presentation of the latest achievements 
in medicine. 


DISEASES OF THE SKIN FOR PRACTITIONERS 
AND STUDENTS: By George Clinton Andrews, A.B., 

M.D., Associate Professor of Dermatology, College of 
Physicians and Surgeons, Columbia University ; Chief of 
Clinic, Department of Dermatology, Vanderbilt Clinic ; 


Fellow of the American Medical Association, of the 
American College of Physicians, and of the New York 
Academy of Medicine. Second Edition, entirely reset. 
899 pages with 938 illustrations. Philadelphia and Lon- 
don: W. B. Saunders Company, 1938. Cloth, $10.00 net. 
The second edition of this work contains seventy- 
five new diseases of the skin. The author has 
added chapters on dermatoses due to filterable vi- 
ruses, vitamin deficiencies and cutaneous infiltration 
with products of metabolism. The author has gone 
into the subject of therapy very thoroughly and 
has added several hundred items such as prescrip- 
tions, sensitization tests and discussions of allergy. 
The work opens with chapters on dermatological 
anatomy and general pathology. The various skin 
diseases are grouped. The writer has given detailed 
instructions in regard to the indications and technic 
of radium and x-ray therapy. The work is well il- 
lustrated and of convenient size. Such works are 
usually written with the general practitioner in mind 
and as textbooks for medical students. This work 
is ideal for both classes of reader. The dermatolo- 
gist will also peruse it with interest. 


INTERNAL MEDICINE: ITS THEORY AND PRAC- 

TICE in Contributions by American Authors, Edited by 
John H. Musser, B.S., M.D., F.A.C.P., Professor of 
Medicine in the Tulane University School of Medicine, 
New Orleans. Third edition, thoroughly revised. Il- 
lustrated. Pages 1,426. Philadelphia: Lea & Febiger, 

1938. 

The second edition of this work appeared four 
years ago. The third edition has been thoroughly 
revised. This is not an easy task when it is con- 
sidered that it is a work of composite authorship 
(twenty-seven contributors). The very fact of 
multiple authorship, however, will assure the read- 
er of thoroughness in the revision since each con- 
tributor has been selected for the special emphasis 
he places on the subject dealt with. The former 




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81 


THE DOCTOR’S LIBRARY 


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editions are too well known as well as the editor to 
call for extended introduction. The book will be 
found not only a convenient single volume practice 
(for it is printed in clear type on light paper) but 
an authoritative work up to the minute on internal 
medicine. 


CANCER, ITS DIAGNOSIS AND TREATMENT. By 
Max Cutler, M.D., Associate in Surgery. Northwestern 
University Medical School, and Franz Buschke, M.D., 
Assistant Roentgenologist, Chicago Tumor Institute, as- 
sisted by Simeon T. Cantril, M.D., Director, Tumor In- 
stitute Swedish Hospital, Seattle. Pages 753, illustrated. 
Philadelphia and London: W. B. Saunders Company, 1938. 

One expressed object of this work is to clarify 
opinion arising out of the controversial literature 
on the subject of neoplastic disease. Recognized 
authorities and leading clinics hold diametrically op- 
posite views upon the management of some of the 
mo4t common forms of the disease (cancer), write 
the authors. The whole field of malignancy is still 
beset with difficulties, not only in diagnosis but also 
treatment, particularly when the x-rays and radium 
are employed with our still uncertain knowledge of 
their action. The work discusses regional mani- 
festations of cancer such as skin, lip, tongue, phar- 
ynx, including every organ in the body as well as 
nearly fifty pages to bone tumors. Thirty-four 
pages are devoted to radiation therapy, that is 
radiation by x-rays and radium. In the matter of 
x-ray treatment, the author not only discusses in- 
dications but draws attention to late manifestations 
requiring caution, particularly in regard to possible 
injuries. The work is a full, almost exhaustive, 
treatise of malignancy which can be recommended 
unhesitatingly to the entire medical profession. 


A BIOLOGICAL APPROACH TO THE PROBLEM OF 

ABNORMAL BEHAVIOR. By Milton Harrington, M.D. 

455 pages. The Science Press Printing Company, 1938. 

In 1934, Doctor Harrington published a volume 
entitled “Wish-Hunting in the Unconscious” in 
which he set forth his criticisms of Freudian Psy- 
chology. His purpose in the present publication is 
to present the psychology which he would offer in 
the place of psycho-analysis. Instead of devoting 
himself exclusively to this objective he continues 
throughout the book to attack the psychology of 
Sigmund Freud. 

The book is divided into three parts. After fifty- 
two pages of First Principles, there follow two 
hundred and three page abo”t o c 
and the remainder of the volume concerns psy- 
chopathology. The author advances no new psycho- 
logical theories in this publication and much of the 
material is a repetition of that which has been pre- 
sented in previous text books on this subject. Doc- 
tor Harrington’s nuclear theme is contained in the 
following statement : “We believe that all forms of 


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82 


Tour. M.S.M.S. 



THE DOCTOR’S LIBRARY 


behavior are produced by the action of an anatom- 
ical mechanism, and that abnormality of behavior 
occurs because of the inadequacy of this mechanism, 
by reason of which it sometimes fails to respond in 
a satisfactory way to the demands made upon it/’ 
To attribute all our thoughts, feelings and actions 
“to the workings of the anatomical mechanism which 
functions in accordance with definite and fixed laws,” 
seems, in the opinion of this reviewer, to deny the 
existence of individuality, to neglect the effects of 
experience, and to ignore the whole concept of 
human personality. The author’s psychology is so 
mechanistic that he repeatedly compares the behavior 
of people to the workings of mechanical devices 
and his arguments are naturally far from convincing. 
Such statements as the following are contradictory 
to the facts of everyday experience : “When afraid, 
for example, one forces himself to assume a bold 
and aggressive attitude and the fear disappears.” 
Similarly, the author states “when angry, one inhibits 
the impulse to clinch his fists, to scowl, to grit his 
teeth, and to speak angrily. Instead he compels his 
body to relax, he smiles, speaks in gentle tones and 
extends his hand in friendly gesture. In behaving in 
this way, one frees himself from the emotion of 
anger, because he frees himself from the postural 
stimulus by which the emotion of anger is main- 
tained.” Everyone knows that we often attempt to 
hide our feelings from others but no one believes 
that .such concealment causes elimination of the 
emotions we experience. To agree with the author 
one would have to believe that human beings possess 
truly magical powers. This book is not a contribu- 
tion to a better understanding of abnormal behavior. 
It is hut another attempt to argue with Freud. 

— Leo H. Bartemeier. 


YEARBOOK OF PHYSICAL THERAPY. Richard 
Kovacs. Chicago: Year Book Publishers, 1938. 

This volume of the Year Book Publishers is an 
outstanding contribution of the fast increasing lit- 
erature in the field of physical therapy. Richard 
Kovacs has been one of the leaders and prolific 
writers in physical therapy, and is well equipped by 
experience to attempt a review of all the material 
which has been published in this field during the 
past year. The first section of the book deals with 
physical therapy methods, and with general dis- 
cussions of the physics, dosage and clinical applica- 
tions. Of particular interest in this .section is the 
discussion of electrophroesis, and its application in 
the treatment of arthritis. The different phases of 
physical therapy — electrotherapy, artificial fever 
therapy, light therapy, balneotherapy and climato- 
therapy, massage and exercise, physical education 
and institutional work — are discussed from the cur- 
rent literature of the past year. The second part 
of the book deals with the practical applications of 
the various physical modalities. Adequate space is 
devoted to the application of physical therapeutic 
measures in cardiovascular conditions, peripheral 
vascular disease, pulmonary and abdominal condi- 
tions, arthritis and rheumatic conditions, traumatic 
and orthopedic conditions, paralyses, neurologic and 
mental conditions, and general discussions on pediat- 
ric, gynecologic, genito-urinary, venereal (gonorrhea 
and syphilis), proctologic, dermatologic, ophthalmo- 
logic and nose and throat conditions. This book is of 
value to both the general practitioner and specialist 
in that it reviews all recent literature in the treat- 
ment of disease by physical modalities. The author 
is to be highly commended for his efforts in com- 
piling and so well arranging the literature in book 
form. Reading is easy, and information is practical. 
All in all this book constitutes a real addition to 
good reading matter in the field of physical therapy. 


NEW AND NONOFFICIAL REMEDIES, 1938. Con- 
taining descriptions of the Articles Which Stand Accepted 
by the Council on Pharmacy and Chemistry of the 
American Medical Association on January 1, 1938. Cloth. 
Price, $1.50. pp. 592, LXVI. Chicago: American 

Medical Association, 1938. 

New substances described in this volume are 
Sulfanilamide and Protamine Zinc Insulin, with the 
accepted brands. The proved value of these new 
additions to the physician’s armamentarium bids 
fair to make the past year a milestone in therapeu- 
tic progress. The Council is to be congratulated on 
the promptness with which it evaluated these drugs 
and established standards for their adequate control. 
From the first the Council warned against using 
Sulfanilamide in untried combinations. The sad 
tragedy of the deaths from the rashly introduced 
Elixir of Sulfanilamide-Massengill starkly empha- 
sizes the value of such a body as the Council to 
the medical profession and the pharmaceutical manu- 
facturers as well as to the public. Of course this 
potential value cannot become effective as long 
as those concerned refuse to follow the Council in 
the use of new remedies. 

Other noteworthy new drugs which ap- 
pear in New and Nonofficial Remedies, 1938, are 
Avertin with Amylene Hydrate, Vinethene, Ponto- 
caine Hydrochloride, basal, general and local anes- 
thetics respectively ; Novatropine and Syntropan, 
synthetic mydriatics. 

Physicians who wish to know why a given prop- 
rietary is not described in New and Nonofficial Rem- 
edies will find the “Bibliographical Index to Proprie- 
tary and Unofficial Articles Not Included in N.N.R.” 
of much value. In this section (in the back of the 
book) are given references to published articles 
dealing with preparations that have not been ac- 
cepted. These include references to the Reports of 
the Council, to Reports of the A.M.A. Chemical 
Laboratory and to articles that have appeared in 
The Journal. 


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January, 1939 


83 


AMONG OUR CONTRIBUTORS 


Among Our Contributors 


Dr. Emil Amberg was born in Santa Fe, New 
Mexico. He graduated from the University of 
Heidelberg, Germany, and was granted the license 
to practice medicine in Germany in 1894. His thesis 
for the doctor’s title was written under the guidance 
of Professor Kraepelin. It led to the discovery 
of the “Warming-Up-Effect.” He was interne in 
the Ear Department of the Massachusetts Charitable 
Eye and Ear Infirmary, Boston, Massachusetts, from 
January, 1896, to April, 1897. He is connected with 
several institutions in Detroit in his capacity as 
otologist. 

* * * 

Dr. James B. Blashill was graduated from the 
University of Michigan in 1927 with an A.B. degree 
and in 1930 with the M.D. He was associated with 
Dr. R. L. Fisher as resident in medicine and with 
Dr. Alexander Blain as resident in surgery at the 
Alexander Blain Hospital. Dr. Blashill has been 
in private practice in Detroit since 1933. 

* * * 

Dr. Willis L. Dixon is a graduate of Loyola 
University, 1916. He holds the position of consult- 
ing pediatrician, St. Mary’s Hospital, Grand Rapids, 
Michigan, at the present time. 

:jc if: 

Dr. Charles H. Frantz is a graduate of the 
University of Michigan, 1932. He served his in- 
ternship at Blodgett Memorial Hospital, 1932, was 
orthopedic resident, Blodgett, 1933 ; pathology resi- 
dent, University of Michigan Hospital, 1934, and 
orthopedic resident, Blodgett Hospital, 1935. He 
is associated with Dr. John T. Hodgen in practice. 

* * * 

Dr. E. E. Hammonds was graduated from 
Washington University in 1934. He is now in 
private practice limited to internal medicine, in 
Birmingham, Michigan. 

* * * 

Dr. Edwin W. Hirsch of Chicago is a grad- 
uate of the University of Chicago, 1914, and of the 
Rush Medical College, 1916. He is attending 
Urologist at the Englewood Hospital, and Associate 
Urologist at the Mt. Sinai Hospital, Chicago. Dr. 
Hirsch limits his practice to Urology. 

* * * 

Dr. Sumner L. Koch of Chicago is a graduate 
of the Northwestern University Medical School, 
class of 1914. He is Associate Professor of Sur- 


gery, Northwestern University Medical School and 
attending surgeon of the Passavant Memorial and 
Cook County Hospitals. 

* * * 

Dr. Earl G. Krieg of Detroit was graduated 
from Wayne University Medical School in 1925. He 
is instructor at the Wayne University Medical 
School, Junior Associate Surgeon in Gynecology at 
Receiving Hospital, Junior Attending Surgeon at 
Woman’s Hospital, and Associate Attending Surgeon 
at the Alexander Blaine Hospital. 

* * * 

Dr. Louis D. Stern of Detroit received his 
A.B. degree from the University of Michigan in 
1912, and M.D. in 1916. He had a Fellowship in 
Hematology at the Harvard Medical School, 1920-21. 
From 1921 to 1926 he was Instructor in Internal 
Medicine at the University of Michigan Medical 
School. Dr. Stern is now in private practice, limit- 
ing his work to internal medicine, and is attending 
physician at the Deaconess Hospital and North End 
Clinic. 


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employment.” 

“Yep,” answered Farmer Corntossel, “I don’t 
blame him. Everybody feels occasionally like gettin’ 
away an’ lookin’ fur work ’stid o’ stayin’ where he 
knows it’ll be waitin’ for him regular.” 

Author, Author! 

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as to go around the country begging?” 

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84 


Iour. M.S.M.S. 



THE JOURNAL 


OF THE 

Michigan State Medical Society 



ISSUED 

MONTHLY UNDER THE DIRECTION 

OF THE COUNCIL 

Vol. 38 

FEBRUARY, 1939 

No. 2 


FRACTURES INVOLVING THE ELBOW* 
KELLOGG SPEED, M.D. 

CHICAGO, ILLINOIS 



The humerus, ulna and radius, singly or in combination, are involved 
in fractures into and about the elbow joint. This diathrodial joint is 
classified as a ginglymus which permits hinge-like motions within a cer- 
tain arc, the exact range of which must be known by the physician deal- 
ing with fractures of the area. This arc of motion extends from an 
angle of about 30° made by the forearm with the arm (humerus) when 
the forearm is fully flexed, to 180°, or a straight angle, when the fore- 
arm is fully extended, giving a total range of motion of approximately 
150°. In some adolescents, particularly in girls, the degree of extension 
may naturally be greater than 180° when the joints are allowed to re- 
lax from stretched or immature ligaments. 

In addition to this range of motion as a 
hinge, we find that the forearm is attached 


Kellogg Speed 


to the arm at an angle of about 10° away 
from a straight line to permit the forearm 
to point outward from the body when fully 
extended and yet to bring its long axis di- 
rectly over the long axis of the humerus 
when fully flexed. This deviation at the el- 
bow is called the carrying angle, made pos- 
sible by an angle of attachment of the fore- 
arm bones to the humerus and a slanting off 
of the lower articular surface of the humer- 
us itself — each equalling 5°, totalling 10°, 
and permitting the exact folding over of 
forearm onto an arm axis in flexion. 


This one point in the structure of the 
elbow is most important in determining dis- 
placement after some of the - ^[gcthr^F 
around the joint, in guiding /n^ reduction 


M 


and immobilization of the fracture and in 
the prognosis after healing of the injury. 

Of equal importance with the gross archi- 
tecture of the joint is the strong capsular 
ligament arranged to bind olecranon and 
coronoid to humerus reinforced by a tough 
annular ligament about the head of the 
radius holding it to ulna and external con- 
dyle of the humerus, and the supporting 
collateral ligaments extending on either side 
from humerus to ulna and radius. These 
firmly bind the joint and yet on account of 
the limited range of its hinge motion we 
find that the bones themselves assist in this 
restriction. The olecranon projecting be- 
hind and within the limitation of these liga- 
ments makes excursion up into the ole- 
cranon fossa of the humerus in full exten- 


sion' of the forearm and by impinging in 
this fqssa limits extension. A similar ac- 

Read before the Seventy-Third Annual Meeting of the tlOn exists in fleXlOn when the COEOnOld 


Michigan State Medical Society, Deftoit, September M , ^ of the ulna occupies the depths of 


February, 1939 




OF 


105 



FRACTURES INVOLVING THE ELBOW— SPEED 


the coronoid fossa of the humerus in the 
front of the joint limiting forearm flexion 
with the help of the interference of the 
muscle masses in the front and the strong 
pull of the triceps tendon in the back of the 
joint. Pronation and supination of the 
forearm, obtained by rotation of the head 
and shaft of the radius about the ulna, are 
independent of forearm flexion and exten- 
sion and may be limited by the simple proc- 
ess of fixation of radius to ulna, either by 
adhesions, change in shape of the round 
head so that it cannot run wheel-like on the 
articulating surface of the ulna or by 
angular displacement of the neck of the 
radius or upper end of the ulna. 

To recapitulate, we have then a joint con- 
stantly useful to all arm motions, hinge- 
like in action with accessory rotation func- 
tion, closely packed with its three compo- 
nent bones bound snugly by strong liga- 
mentous envelopment. Fracture of any 
part of these three bones even of minor de- 
gree, or involving cartilaginous surface, or 
in infancy and youth disrupting the grow- 
ing epiphyses (for discussion of which space 
is lacking) requires careful diagnosis, skill- 
ful attention and a guarded prognosis. 

Based on anatomical structure the elbow 
bones yield by fracture as a result of trans- 
mission of force up the forearm in falls on 
the hand. This may lead to supracondylar, 
or condylar fractures of the humerus or 
fractures of the head and neck of the ra- 
dius. Force transmitted through the flexed 
forearm or on the elbow area directly may 
result in splitting fractures of the lower end 
of the humerus, the coronoid process of the 
ulna, the olecranon or isolated condylar 
fractures. The added indirect action of 
muscle pull may cause some fractures of 
the olecranon or dislocations of the joint 
as a whole. These injuries are found at all 
ages, from the infant just starting to walk, 
to old age. Let us discuss a few of them. 

Supracondylar fracture of the humerus 
may be considered the typical elbow frac- 
ture of infancy and adolescence and may 
pass through the epiphyseal plane wholly or 
in part. Rarely there is no displacement of 
fragments, but usually the distal fragment 
(elbow articular portion) with its closely 
attached forearm bones, is displaced back- 
ward and inward, leading to two planes of 
displacement as viewed from before back- 
ward, or laterally. This separation of bone 


with stretching or tearing of surrounding 
soft parts may catch the near-lying median 
or ulnar nerves causing primary disturb- 
ance of their function, even severing them, 
or later interfering with their action by in- 
clusion in callus or scar tissue. An appar- 
ent change in the carrying angle from this 
loosening of bony support just proximal to 
the elbow joint must result. The elbow 
joint relationships proper are not changed 
because supracondylar fracture is practical- 
ly always extra articular, but the loss of 
support of the humerus just above the joint 
lets the heavy forearm hang or sag, thus 
modifying this important angle governing 
relationship between forearm and arm. If 
the carrying angle is not restored and the 
posteriorly displaced fragment of the hu- 
merus is not brought forward into normal 
relationship with the shaft, there will result 
loss of full range of motion in the elbow 
region with functional loss of use of the 
arm. 

For reduction, with help of counter trac- 
tion on the arm by some one assisting, the 
forearm is first slightly hyperextended, 
avoiding further injury of soft parts about 
the elbow and thinking always of the ten- 
sion on the blood vessels and nerves, then 
pulled out in its long axis by traction on 
forearm and hand, followed by flexion of 
the forearm during maintenance of this 
traction. This third part of the act of re- 
duction is most important as the forearm’s 
long axis must be carried steadily to coin- 
cide with the long axis of the arm and 
brought up to 40° or 35° of flexion with 
the arm, the palm of the hand directed to- 
ward the shoulder. With the help of the 
normal anatomical support about the elbow, 
this should restore the carrying angle and 
give reduced coaptation of fracture sur- 
faces. 

This position must be sustained by a 
well-applied posterior or posterior and an- 
terior moulded plaster of Paris splint, ex- 
tending to base of the fingers for a long 
enough time, depending on the age of the 
patient, to ensure bony healing. If the sup- 
port is removed too soon in any yielding 
to the patient’s desire to get out of splint or 
to any fear of stiff joint resulting from 
lack of motion, two results may follow. In 
the first the weight of the forearm and 
hand may bend the soft callus and thus re- 
produce some of the posterior and angular 

Tour. M.S.M.S. 


106 


FRACTURES INVOLVING THE ELBOW— SPEED 


displacement changing the carrying angle 
unfavorably, interfering with the final use- 
ful range of motion. 

A similar result may follow inadequate 
immobilization when the plaster dressing 
does not extend high enough on the arm 
segment, thus permitting freedom of rota- 
tion of the proximal fragment of the hu- 
merus and a slipping off at the fracture site. 
To avoid this disaster the plaster splint may 
be run up over the scapular region locking 
arm to torso, or in extreme cases in very 
steep and oblique fracture the whole arm 
should be encased in plaster, palm toward 
shoulder and the dressing incorporated in 
a plaster of Paris torso cast, embracing the 
body, resting on the padded iliac crests. 
This ensures no slipping of a properly re- 
duced fracture. 

A second untoward result may follow too 
early attempts at motion, either active or 
passive. These may set up additional sec- 
ondary and untoward new bone formation 
to interfere with the joint motion. Main- 
tain the immobilization, therefore, long 
enough to avoid these dangers, to permit 
the periarticular extravasation to absorb 
and the callus to harden, then use only ac- 
tive motion short of pain. To this control 
of the joint the physician adds unlimited 
patience and encouragement and the final 
joint range of function will be maximal. 
Each exercise of active motion must carry 
the forearm back to full flexion which posi- 
tion after removal of the splint at the end 
of the third week may be held, especially 
at night, by temporary reapplication, until 
all fear of losing full flexion is passed. 
During the day the arm may be carried in 
a sling for safety and convenience. The 
functional results after supracondylar frac- 
ture are seldom perfect, but the physician 
must aim to restore motion and a good car- 
rying angle in an arc of usefulness, which 
means ability to flex the forearm so that the 
hand may reach the face for the purpose of 
eating, attending to hair or shaving, and 
ability to button clothes. When the frac- 
ture is not reduced, these acts will be lost 
in whole or in part. 

Forceful repeated passive motions are 
seldom profitable in attempts to restore el- 
bow ioint motion and function. They usu- 
ally lead to additional blood extravasation 
about the joint, formation of more new 
bone and constricting fibrous tissue with 


resulting reduction of the range of joint 
motion. A small percentage of these frac- 
tures, seen late and unreduced, may be 
coaxed back into near reduction by a proc- 
ess of gradually increased flexion of the 
forearm, held in a successive series of 
moulded plaster splints as new angles of 
forearm flexion are gained. Ancient cases 
with gross deformity, lack of range of mo- 
tion or much new bone formation may be 
operated upon by a qualified surgeon who 
will exercise great care to avoid further 
new bone formation, so easily met with in 
adolescence. A few of these poorly func- 
tioning joints in adults may warrant ar- 
throplasty. 

Fracture of either the external or inter- 
nal condyle are caused by falls on the fore- 
arm or elbow or lateral flexion force re- 
ceived on the forearm and transmitted to 
the humerus, usually without injury of the 
collateral ligaments of the joint. Fracture 
of the external condyle may accompany 
fracture or subluxation of the head of the 
radius and the broken fragment of the 
humerus, depending on the age of the pa- 
tient, may involve the epiphysis, passing 
completely or partially through it. The 
fragment of the humerus in children is al- 
most universally displaced outward and 
rotated, pulled by muscles taking origin in 
this area. Fractures in industry and in 
adults may be comminuted. All of these 
directly involve the elbow joint and lead to 
hemarthrosis and a marked tendency to 
change the carrying angle, letting the fore- 
arm angulate outward into cubitus varus. 
On the inner aspect of the elbow the frac- 
ture is not always truly intra-articular, but 
may involve not only the epiphysis but also 
the epicondyle and its attached muscle ori- 
gins. There is no doubt that the tug of the 
muscles causes rotation of such fragments 
and interferes with manipulative reduction 
and retention by ordinary splinting meas- 
ures, no matter in what degree of flexion or 
extension the forearm is maintained. The 
median, radial or more often the ulnar 
nerve, singly or in combination, may be 
involved in the primary trauma or in th~ 
healing process by inclusion in scar or callus 
or from long standing trauma and stretch- 
ing when epiphyseal and bone growth has 
been interfered with. From internal con- 
dylar fractures develops late the well 
known clinical type or delayed ulnar palsy, 

107 


February. 1939 


FRACTURES INVOLVING THE ELBOW— SPEED 


which may not manifest itself until years 
after the original injury. 

The radiographs of these injuries, which 
occur at all ages, must be closely examined 
and supplemented by oblique views on oc- 
casions when there is any doubt about the 
displacement of bone and cartilage. Frag- 
ments of either, with muscle attachment or 
free, may become obstacles in the joint to 
obstruct full flexion or extension and may 
cause excess new bone formation with in- 
creasing diminution of joint range or late 
nerve symptoms. In viewing the roentgeno- 
gram the cartilaginous portions of the hu- 
merus entering the joint in young children 
are frequently overlooked on account of 
their shadow casting power or their silhou- 
ette on the film being overlapped by heavy 
bone. 

Complete reduction by manipulation may 
be impossible; it is often very uncertain. 
Nearly all of these fractures require open 
operation to search the joint for small 
dropped in fragments and to correct quite 
positively the great amount of rotation of 
fragments, at times equalling 180 °, to fit 
them exactly into normal position. This 
may necessitate freeing the fragment from 
muscle origins, but these severed attach- 
ments can be dropped back into place and 
rapidly take hold again without noticeable 
functional loss. The fragment of bone and 
cartilage should be held in proper place by 
suture or fixation, using that material 
which suits the individual case the best. 
After considerable experience, I find that 
catgut ordinarily suffices, especially when 
the fragment is fully freed and not attached 
to the humerus under any tension. There 
is no objection to nailing on with a small 
wire nail if the fragment is not split or 
damaged. These operations are delicate and 
require a nicety of technic and had best be 
performed by a qualified surgeon in con- 
trolled surroundings. There is no hurry 
about the surgery — a few days makes no 
difference and may be required to perfect 
skin or other conditions. What is done at 
the operation is permanent and even the 
greatest care may result in some loss of 
function in the joint. Immobilization after 
fixation or reduction by any method must 
be quite prolonged and the forearm is gen- 
erally kept in flexion during this period. 
Rarely the fragments can be held apposed 
only when in a position of complete exten- 


sion. One waits for all traumatic insult to 
quiet down and the bone to become annealed 
before starting active movements, which are 
guarded, which aim to keep a full amount 
of useful flexion and not cause pain or new 
bone formation. Final results are reached 
after six to twelve months. 

Some long neglected cases can be bet- 
tered by late operation, but seldom by ma- 
nipulation. This class may involve median 
and ulnar nerves leading to delayed palsies 
and treatment by neurolysis or transplanta- 
tion of the nerve out of harm’s way. 

The grossly comminuted and widely sep- 
arated fractures of the humerus into the 
elbow joint resulting from falls or blows 
are most difficult to reduce and immobilize. 
Suspension traction by adhesive tape on the 
skin with the forearm out in a straight line, 
with intact ligaments, may suffice to hold 
fragments in good position as determined 
by x-ray examination in two planes. After 
two and one-half to three weeks this con- 
fining treatment may be supplanted by a 
moulded plaster of Paris splint, with the 
elbow in partial flexion, increased every two 
weeks. The fragments must not be dis- 
placed or allowed to widen during such a 
course. Others are apparently irreducible 
by this skin traction which may be replaced 
by Kirschner wire traction through the olec- 
ranon with the forearm held flexed at a 
right angle, with the patient either recum- 
bent or ambulatory, using a plaster of Paris 
dressing which embeds the wire, forearm 
in supination and hand supported by the 
dressing. Open fixation is reserved for the 
obdurate case in which a wire cerclage or 
transfixion may be required to bring frag- 
ments together followed by adequate fixa- 
tion in plaster for four to eight weeks. 
Nerve injuries, while infrequent, must be 
searched for at the time of injury and ade- 
quately cared for by suture or neurolysis. 
These operations similarly require well 
trained surgical skill. 

Fractures of the olecranon generally fol- 
low indirect violence or pull of the triceps 
tendon during falls on the flexed forearm. 
They are truly intra-articular fractures and 
may be sutured with wire or other material 
through an open incision. They should 
then be immobilized in nearly full extension 
for two and one-half weeks and active flex- 
ion in mild degree may then be started. 
Some separation of fragments may follow. 

Jour. M.S.M.S. 


108 


POSTOPERATIVE OXYGEN THERAPY— SCHMIDT 


One should not rely too much on any type 
of internal fixation and begin active move- 
ments too soon or too vigorously. There is 
much doubt whether operated upon frac- 
tures of the olecranon, with all the dangers 
inherent to open procedure, give better re- 
sults than those not operated upon, but treat- 
ed by immobilization in full extension with 
graduated use following. One should pon- 
der carefully and operation must not be 
lightly undertaken in these fractures. The 
same careful after-care when splint is re- 
moved is required by both types of treat- 
ment. 

Fractures of the head of the radius occur 
at all ages, even in infancy, and may be ac- 
complished by subluxations from tearing or 
rupture of the orbicular ligament. When 
the infant first starts to walk and is held 
by the hand, subjected to sudden jerks in 
hyperextension of the forearm by accom- 
panying nurse or parent, subluxation or 
“pulled elbow” often results. The child 
cries without apparent cause — but will not 
use the hand of the affected arm. X-ray 
examination should reveal the true condi- 
tion. The reduction may not be difficult but 
recurrence easily follows and the forearm 
should be dressed in full flexion onto the 
arm held by bandage or moulded plaster of 
Paris for three weeks. 

If the head or neck of the radius is 
fractured, the break may be complete or 
incomplete, the latter type existing as cracks 
in the bone running down the head, without 
fragment displacement. These, how T ever, 
are true fractures, they entail hemarthrosis, 


they require immobilization in moulded 
plaster of Paris and a sling support with 
the forearm flexed and in full supination 
for two or four w^eeks depending on the pa- 
tient’s age. 

Fracture of the head of the radius in- 
volving gross displacement in young chil- 
dren may be partly reduced by manipula- 
tions, using pressure over the fragment, fol- 
lowed by flexion of the forearm, fragment 
position to be checked by x-ray. The im- 
mature elbow joint of youth will tolerate 
a certain amount of fragment displacement 
and return ultimate good function if time is 
allowed for bony healing. In adults, how- 
ever, the fully matured and completely 
packed elbow joint will not tolerate dis- 
placements as new bone formation or heal- 
ing on of misplaced fragments will surely 
influence pronation and supination of the 
forearm and may check the range of flexion 
and extension. These patients require care- 
ful x-ray study and examination of elbow, 
forearm and hand. Consultation is usually 
advisable because a fair percentage require 
operative removal of the comminuted head 
which may be found on exposure to be 
more severely fractured than the x-ray ex- 
amination would lead one to believe. Re- 
moval of the head of the radius is a techni- 
cally difficult procedure, to be undertaken 
only by a qualified surgeon who will guard 
against later new bone formation around 
and in the elbow by a proper period of post- 
operative immobilization and a kindly in- 
ception of active use. Very few’ such in- 
juries result in complete functional return. 


POSTOPERATIVE OXYGEN THERAPY 


ERWIN R. SCHMIDT, M.D. 

MADISON, WISCONSIN 

Oxygen, since its discovery in 1775, has played a varying role. At first used in the 
chemical laboratory for experimental work and used therapeutically for the first time in 
1780, it had persisted in remaining there for many years. Into industry it has found 
its way through the laboratory, and in the last two decades it has entered the field of 
clinical medicine. At first the field was extremely limited because of the expense asso- 
ciated with the building of an oxygen room. Soon the results of these investigations 
broadened its clinical use, and, with the advent of oxygen tents, a wider use was pos- 
sible. Today I shall try to demonstrate to 
you how it can be used as widely and gen- 
erally as any well known household remedy. 

First, I want to go into the therapeutic use 
of oxygen and show, if I can, how much 

February, 1939 


more often oxygen should be used, especial- 
ly in the postoperative period of patients. 

In the normal individual, nature has pro- 
vided an excellent mechanism for ordinary 


109 


POSTOPERATIVE OXYGEN THERAPY— SCHMIDT 


use, and also for emergencies. The heart 
has a certain reserve which can be called 
upon, and the liver has so much reserve that 
the normal individual could get along with 
about one-fifth of that amount. Our blood 
chemistry is delicately balanced and pro- 
tected to prevent either an acidosis or an 
alkalosis. The respiratory mechanism is 
adjusted to keep up a sufficient oxygen sup- 
ply for the blood, and to remove carbon 
dioxide gas to prevent an accumulation. 
There are others. Suffice it to point out 
these well known examples. 

In the surgical patient the condition that 
obtains may vary from a surgical condition 
with a complete normal mechanism to one 
with one or more systems partially im- 
paired, moderately impaired or badly dam- 
aged. We have clinical and laboratory 
means to determine the amount of damage 
in some of the systems, and in others ©ur 
means are very inadequate, so that even the 
most perfect evaluation by clinical and lab- 
oratory methods leaves something to clin- 
ical judgment. It is difficult to determine 
the reserve, how soon it will be used up, or 
what insults it will withstand. To protect 
this reserve and prevent it from becoming 
exhausted has been the problem, not only 
for the surgeons but for all medical men. 

The human body is influenced by an op- 
eration in various ways. The anesthetic 
depresses metabolism, reduces reflexes, pro- 
duces a certain amount of acidosis, some 
dehydration, and a leukocytosis of one and 
a half to two and a half times the pre- 
anesthetic count. 4 The operation itself pro- 
duces a lowered general and local resistance, 
pain and fever, and the phenomena of in- 
flammation with the physiologic and path- 
ologic changes attendant upon the type of 
operation performed. This means an extra 
load is put upon the body mechanism, a call 
upon the reserve, and the biggest load 
comes upon the myocardium, which has to 
furnish oxygen and food and remove car- 
bon dioxide and waste products. 

Various factors have been taken care of, 
such as pain, dehydration, and acidosis. 
The heart, which has to bear a tremendous 
load, if it shows signs of weakening, re- 
ceives digitalis, coramine, caffeine, sodium 
benzoate, etc. The use of heart stimulants 
when the heart is overloaded is likened to 
using a switch on a tired horse that is 
stuck with a load. The use of oxygen for 


the overburdened heart, instead of apply- 
ing the switch to the tired horse, takes off 
some of the load. Modern medicine should 
look forward and see if there is a way to 
lighten the load and prevent a breakdown. 

That the load could be definitely light- 
ened was demonstrated to us in a toxic 
thyroid. We used an intranasal catheter 
and ran oxygen into the oropharynx. The 
heart rate, which was 160 per minute, 
dropped to 100. When the oxygen was re- 
duced or stopped the rate immediately in- 
creased to 130. This experience has been 
repeated many times. The experience at 
the Wisconsin General Hospital has shown 
that, in cases in which oxygen therapy is 
effective in reducing the load on the heart, 
the heart rate will decrease in a very short 
time. If in three hours there has been no 
drop in the heart rate, there is little use in 
using oxygen. 

Wright 6 has pointed out that the velocity 
of exchange of a gas between lung and 
blood depended on: (1) pressure difference, 

(2) solubility of the gas in blood, and (3) 

the property of the membrane. We have 
some idea of the effect of oxygen deficiency 
on the human mechanism. Clinically we 
recognize three types of anoxemia as de- 
scribed by Barcroft 1 : (1) the anoxic in 

which the oxygen tension is reduced and the 
hemoglobin not completely saturated; (2) 
the anemic type in which the oxygen tension 
is normal but the hemoglobin is reduced; 

(3) the stagnant type in which the time 
volume of oxygen-laden blood supplied to 
the tissues is low. Boothby 2 adds a fourth 
called the histotoxic in which the cells are 
incapable of using oxygen, as in cyanide 
poisoning. 

The compensatory mechanisms to meet 
this anoxemia are an increase in the ven- 
tilation of the lungs, an increase in the heart 
rate throwing more work on the heart, and 
an increase in the number of red cells. This 
increase takes place as a result of a con- 
traction of the spleen forcing more cells into 
circulation, and an increased activity in the 
hematopoietic system. 

Wiggers 5 shows the chemical changes be- 
tween inspired, alveolar, and expired air un- 
der normal circumstances: 


0 2 per cent C0 2 per cent 

Inspired air 20.92 0.04 

Alveolar air . 14.5 5.3 

Expired air 16.4 3.8 


Tour. M.S.M.S. 


110 


POSTOPERATIVE OXYGEN THERAPY— SCHMIDT 


If the oxygen of inspired air is reduced 
to 14 per cent, the force and the rate of the 
heart are considerably increased. Tissue 
anoxia results in definite parenchymatous 
changes. Brief interruption of the arterial 
supply to the kidney results in anuria for 
hours, and lesser impairment of the circula- 
tion leads to glomerular dysfunction. The 
secretions and movements of the gastroin- 
testinal tract are decreased ; and for various 
tissues there are possibilities of damage, 
from very minimal, which is hard to esti- 
mate, to tissue death. 

Furthermore, we know that the solubility 
of a gas is diminished by the salts present 
in plasma and blood. With an impaired 
circulation, the salts and waste material pile 
up and the solubility is reduced, the mem- 
brane may change, and the rate of breathing 
is impaired as a result of position, anes- 
thesia, or alkalosis. 

Oxygen therapy should be based on a 
clinical evaluation of the patient, the type 
of anoxemia recognized, and appropriate 
measures instituted. If the patient has an 
anemia, oxygen therapy will aid, but the 
addition of a blood transfusion will furnish 
some hemoglobin and stimulate the hem- 
atopoietic system. The lowered tension of 
the oxygen can be remedied by the oxygen 
therapy. This we see every day when fliers 
at high altitudes use oxygen. In the stag- 
nant type the time volume of blood that 
is delivered to the tissues is increased by 
heart stimulation. In the histotoxic type 
the use of phlebotomy with transfusion and 
oxygen is the rational treatment. 

There are conditions in which one’s clin- 
ical ingenuity is taxed. In pulmonary 
edema, the alveolar spaces are filled with 
fluid; in consolidation of the lung, the 
spaces are also obliterated and the epithe- 
lium of the alveolar spaces may be modi- 
fied by gases. By increasing the tension of 
the oxygen a sufficient amount may get 
through the damaged epithelium or fluid to 
keep the patient alive. 

A very important fact to remember in 
oxygen therapy is that there is no store of 
oxygen anywhere in the body. If the body 
needs oxygen, the supply furnished must 
be continuous. Interrupted administration 
is useless. 

Where the respiratory rate does not per- 
mit of an interchange of the alveolar gases, 
the addition of 5 per cent C0 2 to increase 

February, 1939 


its tension and to build up a carbon dioxide 
reserve which will stimulate the respiratory 
center, and allow a proper exchange of 
gases, is very efficacious. 

In clinical work in surgery we are usually 
not dealing with definite types of anoxia. 
In surgery we are increasing the load on 
the systems of the human body, and the first 
evidence comes in an increased heart rate. 
This load we can decrease. To improve 
this situation we can change the oxygen con- 
tent of the inspired air. Rovenstine, Tay- 
lor, and.Lemmer 3 have shown by chemical 
analysis of samples of air from the trachea 
and the bronchus that the percentage of 
oxygen can be definitely increased by the 
oropharyngeal insufflation of oxygen. Their 
findings are shown in Table I: 

TABLE i 

At height of inspiration 

N °.° f 

0 2 c.c. Maximum Average Minimum anal- 
Per Min. 0 2 C0 2 0 2 C0 2 0 2 C0 2 yses 

None 18.8% 1.8% 16.4% 1.7% 15.9% 1.6% 3 


2000-2500 



26.2 

1.7 



1 

4000-4500 

29.5 

2.0 

29.3 

2.3 

29.1 

2.7 

2 

6000-6500 

59.1 

1.5 

57.3 

1.6 

54.4 

1.7 

8 

8000-8500 

65.2 

2.0 

62.5 

1.8 

60.0 

1.6 

4 


At height of expiration 



4000-4500 



31 . 2 % 5 . 7 % 



1 

6000-6500 

56 . 6 % 5 . 6 % 55.1 

5.8 

53 . 6 % 6 . 0 % 

2 

8000-8500 



61.3 

4.9 



1 


From these figures it is definitely shown 
that the oxygen concentration can be accom- 
plished by means of oropharyngeal insuffla- 
tion of oxygen. This means that oxygen 
can be used clinically anywhere, from the 
best equipped hospital to the faVm house. 
It is no longer beyond reach of any practi- 
tioner of medicine, nor need it be limited to 
the postoperative convalescent. Our hos- 
pital is piped for oxygen and the oxygen 
stored in a separate building. Any and 
every patient who needs oxygen gets it. 
Every interne learns in a very short time 
to master the details. An analysis now un- 
derway by the department of anesthesia 
shows how oxygen may be wasted. If there 
is no drop in the pulse rate in three hours 
with the oxygen flowing at six liters per 
minute, it might as well be stopped and the 
oxygen saved. There are cases in which 
it is not necessary, but is used in a routine 
way instead of picking the individual case 
requiring the oxygen therapy. Table II 
gives a report on the oxygen therapy for 


111 


POSTOPERATIVE OXYGEN THERAPY -SCHMIDT 


the last year compiled by the department come dilated and make pressure on the 
of anesthesia: heart. 


TABLE II 


Postoperative Treatment by Agents 

GH 6 Ether N 2 0 Spinals GH« 


No. of cases . . . . 


2343 

531 

476 

278 

189 

Oxygen therapy . 


2.86% 

4.9% 

10.7% 

5.4% 

10.5% 

Intravenous therapy 

2.51 

4.9 

2.9 

11.95 

4.23 

Transfusion 


1.24 

0.94 

1.05 

2.16 

8.46 

Opiates 


26.82 

36.4 

42.2 

68.7 

60.8 

Morphine Combination 

0.26 



0.72 


Carbon dioxide . . 


0.26 

0.75 

0.21 

2.16 


Subcu. & Procto. 


32.1 

27.7 

17.2 

61.8 

23.8 

Miscellaneous 


11.8 

9.62 

13.7 

9.7 

18.5 

Total cases with 

treatment 

67.9 

47.3 

54.9 

86.7 

73.6 


Oxygen Therapy by 

Risks 





Risk 

No. 

Per cent 




E 

2 

1.12% 





A 

3 

1.68 





B 

57 

31.9 





C 

80 

44.7 





D 

32 

17.9 





ID 

5 

2.7 





Oxygen Therapy by 

Services 






Total cases 

Oxygen Therapy 




All services . 

4133 

179 

4.09% 




Surgical . . . . 

1354 


9.97 




Gynecology . 

772 


0.39 




Orthopedic 

760 


0.79 




Genito-urinary 363 


4.13 




Plastic 

142 


4.23 




Ear, Nose & 

Throat.... 237 


1.69 




Eye 

117 


0.85 




Oxygen Therapy by Operation 


Mastoidectomy 

Bronchoscopy 

Cleft Palate 

Cystoscopy 

Bladder operation . . . 

Hysterectomy 

Cholecystectomy 

Splenectomy 

Gastric resection 
Intrapleural operation 

Craniotomy 

Thyroidectomy 

Thoracoplasty 

Rib resection 

Laparotomy, others . . 

Inguinal hernia 

Kraske 


2 Rectal operation 

1 Superficial major 

6 Superficial minor 

1 Other general surgery 

4 Open reduction fracture 

2 Manipulation and cast 

14 Tonsillectomy and adenoidectomy 

1 Other eye operations 

2 Sympathectomy 

I Ventral hernia 

6 Stabilization, reconstruction joint 

~r Urethral dilatation 

" Gastro-enterostomy 

. Transurethral prostatectomy 

5 Suprapubic prostatectomy 

d Nephrectomy 

3 Spinal fusion 

3 Exploration knee 


1 

1 

1 

1 

1 

1 

1 

1 

1 

2 

2 

1 

1 

8 

1 

1 

1 

1 


(A film was shown depicting the technic 
of oropharyngeal insufflation of oxygen.) 

A word to emphasize the proper placing 
of the catheter: By putting the catheter in 
the nostril or nasopharynx a concentration 
of only 30 per cent of oxygen can be ob- 
tained running the oxygen at a rate of six 
liters a minute. If it is properly placed in the 
oropharynx, a flow of six liters will give a 
concentration of 60 per cent or more. Put- 
ting the catheter further down so that the 
esophagus is entered, the stomach will be- 


Conclusions 

1. Patients who present themselves for 
operation should be evaluated, but in spite 
of clinical and laboratory methods the re- 
serve mechanism of the body cannot be ac- 
curately measured; the final determination 
rests upon sound clinical judgment. 

2. An operation and an anesthetic add 
to the demands made on the body reserve. 

3. Certain of these factors have been 
met, such as pain, dehydration, and acidosis. 

Tour. M.S.M.S. 


112 


MENTAL HEALTH— EBAUGH 


4. Rapid heart rate is an early sign of 
increased heart load. 

5. Relief of the myocardial load has 
been only partially met, and treatment post- 
poned until weakness is shown. 

6. Oxygen therapy lessens the myocar- 
dial load and tends to prevent a breakdown. 

7. A technic is shown whereby oxygen 
can be used universally. 


References 

1. Barcroft : Quoted in Wiggers’ Physiology in Health 

and Disease. 

2. Boothby. Quoted in Wiggers’ Physiology in Health 
and Disease. 

3. Rovenstine, Taylor, and Lemmer : Oropharyngeal in- 

sufflation of oxygen, anesthesia and analgesia, 15:No. 1, 
(January-February) 1936. 

4. Taylor and Waters: Leukocytosis following inhalation 

anesthesia. In press — Anesthesia and Analgesia. 

5. Wiggers : Physiology in Health and Disease. 

6. Wright, Sampson : Applied Physiology. 


THE OBLIGATIONS OF THE MEDICAL PROFESSION 
IN RELATION TO MENTAL HEALTH* 

FRANKLIN G. EBAUGH, M.D. 

Professor of Psychiatry, University of Colorado School of Medicine 
Director, Colorado Psychopathic Hospital 

DENVER, COLORADO 

I consider it fitting and proper to introduce the following remarks 
with a series of questions, namely: What is mental health? How may 
we secure it? In what way or ways do we lack it? What would we have 
if we could have it? 

Mental health has been considered from two points of view. 9 First, 
from a positive or direct point of view. There has been in recent years 
a tendency to emphasize mental health as a goal for all society; to con- 
sider mental hygiene a philosophy, a way to life; to state its objective 
as that of a wholesome, happy, well balanced human existence, with 
the hope of maximum adjustment ca- 
pacity to any and all difficulties that may 
present themselves in a life course. This 
positive concept of mental health is being 
appreciated in an increasing manner. But 
with the positive, there is a negative phase. 

This is and has been the scientific approach 
to the various deviations from healthy and 
wholesome living. It is this phase which 
has led to a more thorough understanding 
of the healthy person. That this has been 
the method of scientific approach in physical 
medicine must appear obvious to you. One 
need only recount the chapters of progress 
in infection, nutrition and degeneration to 
understand the evolution of knowledge that 
has led to a better appreciation of growth, 
metabolism, and immunity. 

In its earlier days, mental hygiene had 
to do with the more conspicuous and ob- 
vious deviations of behavior, namely, insan- 
ity. That this remains as part of the work 

*Read at the Annual Meeting of the Michigan State 
Medical Society, Detroit, Michigan, Wednesday, Septem- 
ber 21, 1938. 

February, 1939 113 


set out for mental hygienists is apparent. 
A statistical statement of the problem of 
mental disorders in our nation today reveals 
the need for further and more intensive 
study of cause, course and outcome of ab- 
normal behavior. 

Yet, there has been a tendency to asso- 
ciate mental hygiene with the consideration 
of the subnormal, the psychopathic, the de- 
linquent, the eccentric, to the exclusion of 
what has been termed the positive phase of 
the movement. Important as the negative 
phase is, it is apparent that it is not the only 
significant aspect. In other words positive 
mental health is considered as the real goal 
of mental hygiene. In his Salmon lectures, 
White stated: 10 

“The mental hygiene movement is essentially, as 
it exists today, a public health movement which has 
as its major objective the prevention of the dis- 
abilities and wastage of mental disease. It has 
as its goal what I think can best be defined as 
the good life, perhaps qualified by the additional 
words well lived. Its realm is what I would call 
the psycho-social level of development, and its 



MENTAL HEALTH— EBAUGH 


methods must be evolved from the basic facts that 
are contributed by the various sciences which make 
for the understanding of human behavior.” 

Scientists, physicians, educators and 
sociologists are becoming increasingly aware 


has made genuine and permanent progress 
and that the student of today is well pre- 
pared for entrance to the medical school. 
He finds organized adequate instruction in 
both the preclinical and clinical years. How- 


OUTLINE FOR PSYCHIATRIC TEACHING 4 



A 

CLINICAL 


* 



PRECLINICAL 


of the need to understand and develop the 
positive phase of mental hygiene. 

In the following I shall try to point out 
the progress which has been made in 
psychiatric education. This shall help us to 
comprehend the means by which the student 
of medicine becomes prepared to understand 
both phases of mental hygiene. 

Time will not permit a thorough review 
of the historical steps in the improvement 
of medical education. Suffice it to say, that, 
in the past three decades, medical education 


ever, without depreciating these steps, it 
must be stated that the study of medicine 
has wandered somewhat from its primary 
and original purpose, namely, the study of 
man in health and disease. There has been 
a tendency to devote an undue amount of 
attention and effort to organ and system 
function to the neglect of the integrated 
unit of personality. That a correction of 
this tendency is in process is evidenced by 
the adoption of standards for the teaching 
of psychiatry . 3 This has led, naturally, to 

Jour. M.S.M.S. 


114 










MENTAL HEALTH— EBAUGH 


consideration of premedical preparation, in 
which it is hoped that the students of the 
future will be better grounded in the social 
sciences together with chemistry, physics, 
and biology ; and to the introduction of four- 
year psychiatric teaching programs in the 
medical schools. The purpose of the latter 
is to introduce the study of normal personal- 
ity through attention to the concept of 
psychobiology. This enables students to un- 
derstand themselves and to comprehend the 
variations of personality behavior which 
may be encompassed within the normal 
range. In the second year of medicine the 
student is taught the methodology of ex- 
amination as well as the concept of psycho- 
pathology, the study of the content and mo- 
tivation of abnormal behavior. In the clin- 
ical years he is taught to recognize, under- 
stand and treat the various personality de- 
viations which occur in children and adults. 
(A slide was shown demonstrating the four- 
year plan of psychiatric instruction.) 

This, then, has led the physician to recog- 
nize, understand and utilize the two phases 
or objectives of mental hygiene. 

To return to the direct, immediate or 
positive phase of mental hygiene, namely, 
the understanding of self, leads one to con- 
sider its nature and necessity. It is my 
belief, that the personality study which 
is done by the freshman student, together 
with the course in psychobiology, is of 
inestimable value in securing a more thor- 
ough understanding of self. Through such 
understanding one may gain a way of life 
that shall enable one to attain the optimum 
of mental health and personality develop- 
ment. In the study of man, in particular 
relation to maldevelopment, injury and dis- 
ease, which is our chosen field, it is more 
than necessary for us to understand our- 
selves. In this respect the aim of mental 
health may be defined as “the adjustment of 
individuals to themselves and the world at 
large with a maximum of effectiveness, sat- 
isfaction, cheerfulness and socially consid- 
erate behavior, and the ability to face and 
accept the reality/’ 7 

One can readily understand how the posi- 
tive phase of mental hygiene is preventive 
in nature. I believe sincerely that mental 
hygiene leading to better personal and inter- 
personal adjustment does and will prevent 
some degree of the personality disorders, 

February, 1939 


common to each of us and present in the 
neurotic and psychotic groups. 

Proceeding, then, to the second obliga- 
tion of the medical profession in relation to 
mental health, the recognition, interpreta- 
tion and treatment of the more manifest 
mental disturbances, we approach the prob- 
lem as it exists today. 

It will not be possible to discuss thorough- 
ly the mental health problems as they exist 
in the schools and colleges. Nor will it be 
within the scope of this paper to deal with 
problems of delinquency and crime. Suffice 
it to say that the general practitioner is 
often the “first man on the scene” when 
“Johnny” or “Mary” is brought to him for 
advice concerning impersonal, personal or 
interpersonal difficulties. We believe it is 
necessary for the physician to be able to 
understand, at least in part, the motivation 
of the antisocial or asocial child and to be 
able to recognize problems of sufficient se- 
verity to need expert aid. The work 
that has been done by physician-psychiatrist 
in the pre-school, grammar, secondary and 
college divisions of education has pointed 
out the need for a change in educational 
standards which will lead to a goal of hap- 
pier and more wholesome living. In this 
respect, the studies of Raphael 8 in the Uni- 
versity of Michigan should be mentioned. 
During the seven years the Mental Hygiene 
unit of the Student Health Service has op- 
erated in Ann Arbor, it has given attention 
to 4,769 students. Surely, this work is 
fundamental to any mental hygiene ap- 
proach. 

In a more pertinent vein, one proceeds 
to the problem of the personality disorders 
as they are seen by the general practitioner. 
One may ask what is the nature of the 
psychiatric problems most frequently en- 
countered in general practice? Is it neces- 
sary or desirable for the average physician 
to refer all of these problems to the specialist 
in mental disorders? What is a necessary 
minimum to enable the physician to recog- 
nize, understand and treat the various and 
sundry people who suffer from personality 
disturbances ? 

In answer to the first question, the phy- 
sician encounters any and every type of 
personality deviation. However, there are 
some disturbances which occur more fre- 
quently than others and some of these, such 
as the anxiety syndromes, the depressions. 


115 


MENTAL HEALTH— EBAUGH 


early schizophrenic reactions, the toxic or- 
ganic and the organic groups will be dis- 
cussed in some detail. 

It is neither necessary nor desirable for 
the physician to refer all cases to a special- 
ist. As has been stated previously, the pres- 
ent aim of psychiatric education is to pre- 
pare the physician to deal with most of these 
problems in a sympathetic and efficient man- 
ner. As to the necessary minimum of in- 
formation we believe that a planned study 
of the personality factors involved in psychi- 
atric disorders greatly enhances the likeli- 
hood of successful therapy, although we all 
know of highly gifted clinicians who deal 
more or less successfully with many of 
them without this aid. Everyone agrees 
that emotional, social, situational and kin- 
dred factors may cause complications in 
any somatic illness, but without some sym- 
pathetic knowledge it is difficult to deal ef- 
ficiently with the mass of facts accumulated 
by investigation. As an aid to the prac- 
titioner we recommend the outlines for in- 
vestigation of the past history, the family 
situation and heredity, the origin and de- 
velopment of the present illness, the under- 
lying personality of the patient and the 
specific symptoms and signs of the various 
reaction types which may be found in any 
of the standard textbooks of psychiatry. 

(With the aid of the lantern slides which 
followed, the significant findings of the his- 
torical data and examinations which should 
suggest various reaction types were shown.) 

It should be clearly understood that out- 
lines such as these are, are far from being 
complete and are utilizable only in the sense 
of orientation in diagnosis. 

DATA WHICH WOULD SUGGEST BEHAVIOR 

DISORDERS IN CHILDREN 
(modified from Kanner 6 ) 

I. In connection with Physical Illness. 

a. Mental Deficiency 

1. Hereditary and congenital — mongol- 
ianism, amaurotic family idioc), syph- 
ilis. 

2. Acquired — encephalitis, meningitis, 
trauma, cretinism, convulsive disor- 
ders, etc. 

b. Transient disturbances during and follow- 
ing somatic illness. 

II. Part Dysfunctions. 

Constipation, enuresis, tic. 

III. Whole Dysfunctions. 

a. Unhealthy emotional reactions (fear, 
anger, spite reaction). 


b. Thinking difficulties (day dreaming, lack 
of attention and concentration). 

c. Acute social trends (disobedience, lying, 
stealing, truancy, cruelty). 

d. Sexual disorders (masturbation, homo- 
sexual and heterosexual activity). 

e. Disorders of sleep (insomnia, hypersom- 
nia, inversion of sleep rhythm). 

f. Faulty teething habits (capricious appe- 
tite, loss of appetite, etc.). 

g. Habitual manipulation of body (chewing, 
sucking fingers, clothes, etc.). 

h. Attack disorders (typical and atypical con- 
vulsive disorder). 

i. Major and minor psychosis (hysterical, 
anxious attacks, manic, schizophrenics). 

DATA WHICH WOULD SUGGEST PSYCHO- 
PATHIC PERSONALITY 

1. Early evidences of poor emotional control: tem- 
per tantrums, moroseness, self assertion, unde- 
pendability, impulsiveness, egocentricity, queru- 
lousness. 

2. Long history of asocial or anti-social behavior 
with vagabondage, drug addiction, prostitution, 
crime, etc. 

DATA WHICH WOULD SUGGEST MENTAL 
DEFICIENCY 

1. Evidence of physical and intellectual retarda- 
tion, as in age of walking, talking, school rec- 
ord. 

2. Formal psychometric tests (Stanford-Binet). 

3. Hereditary and congenital feeblemindedness, 
mongolianism, amaurotic family idiocy, cretin- 
ism, syphilis. 

4. Developmental deficiency, meningitis, encephali- 
tis, trauma, etc. 

DATA WHICH WOULD SUGGEST PARANOID 
REACTION 

a. Rigid, proud, sensitive and suspicious person- 
ality. 

b. Inability to adapt to reality or to sense the 
need for correction. 

c. Irresistible tendency to systematization by false 
interpretation. 

d. Projections in the form of jealousy, persecu- 
tions, interpretations, and the urge for vindica- 
tion. 

Anxiety Syndrome 

And now, in more detail, a consideration 
of those syndromes frequently encountered 
in general practice with some remarks as to 
therapy. 

DATA WHICH WOULD SUGGEST PSYCHONEU- 
ROTIC REACTION TYPE 

1. Excessive prolonged concern over essentially 
normal bodily functions. 

2. Anxiety states with fear of impending disaster 
and bodily expressions of headache, palpitation, 
tension, sweating, etc. 

3. Obsessive thoughts, ritualistic behavior and mo- 
tor tics which appear to be inescapable even 
with awareness of their essential uselessness and 
“foreignness” to the person. 

4. The cutting off of essentially normal functions 
and experiences from participation in life ac- 
tivity with loss of ability to return them to use. 
Hysterical paralyses, anesthesias, amnesias, 
dream states and fits. 


116 


Tour. M.S.M.S. 


MENTAL HEALTH— EBAUGH 


First, in respect to the psychoneuroses, 
the most common type is that of anxiety. 
While the general practitioner does encoun- 
ter many personalities with hysterical and 
obsessive-compulsive symptomatology, it is 
the anxiety syndrome and its aromatic re- 
percussions that he meets most often. 

The anxiety syndrome 5 was first described 
by Hecker in 1893 but did not receive gen- 
eral recognition in this country until after 
the war. It has been known by many mis- 
leading terms, including “disordered action 
of the heart,” irritable heart, neurocircula- 
tory asthenia, et cetera. 

The clinical picture varies in the num- 
ber, character and severity of the subjec- 
tive and objective symptoms. This is de- 
pendent upon the underlying personality 
matrix of the individual. It is important to 
understand that the person is basically anx- 
ious and that anxiety syndromes may be 
symptomatic of other mental disorders such 
as depressions, schizophrenia, and even or- 
ganic disturbances associated with paresis 
and trauma. The anxiety may be associated 
with some physical disease such as tuber- 
culosis, thyrotoxicosis, diabetes or pernic- 
ious anemia. It always occurs in an indi- 
vidual who is inclined to be tense and un- 
easy, with rather sudden transient attacks 
varying in duration from a few seconds to 
an hour and associated with palpitation, pre- 
cordial discomfort, perspiration, dyspnea, 
weakness, giddiness and even fainting. 
Although the symptoms mentioned obvious- 
ly suggest disease of the various systems, 
the physician can elicit the presence of the 
anxiety, i.e., a fear of danger from within, 
a fear of illness or death, or only a feeling 
of uneasiness or impending danger. The 
patient may remark further that he has dif- 
ficulty in sleeping, anorexia, easy fatigue, or 
headache, often of the “band around the 
head” variety. The patient may be irrit- 
able, restless, losing weight, or worried 
without knowing what about or why. A 
subjective feeling of being cold and unable 
to warm up is frequent. Direct examination 
reveals usually a tense, restless, uneasy, ap- 
prehensive person with cold, clammy hands 
and feet, dry mouth and labile pulse and 
blood pressure which are normal when the 
patient is asleep. The heart tends to hyper- 
activity with an occasional premature con- 
traction; the colon may be tender to palpa- 
tion and the muscle and tendon reflexes fre- 


quently are overactive. We have found the 
peaks of highest age incidence to be between 
the ages of twenty-one to twenty-five and 
thirty-six to forty years. 

As stated previously, the differential diag- 
nosis should entail consideration of the 
“symptomatic” anxiety states which may be 
associated with somatic illness (tuberculosis, 
hyperthyroidism, diabetes, anemia, etc. ) ; 
those resulting from central nervous system 
involvement (arteriosclerosis, paresis, trau- 
ma) or those appearing as presenting com- 
plaints in the functional mental disorders 
(depressive and schizophrenic reactions). 

It should be emphasized that the diagnosis 
of a psychoneurotic reaction pattern is not 
done through exclusion. Oftentimes, we 
hear the remark that if a careful search for 
somatic findings is negative, one must come 
naturally to the diagnosis of a neurotic reac- 
tion. But the diagnosis of such a complex 
phenomenon entails positive as well as nega- 
tive facts. These positive facts are the data 
of the personality which informs us of the 
endowment, experience and capacity of the 
person. 

In treating a patient with an anxiety syn- 
drome, having taken care to rule out any 
direct or indirect somatic factors which may 
be causal in nature, we approach the prob- 
lem of the anxiety syndrome itself. It is 
important to avoid the pitfalls of telling him 
that he should stop worrying, or that noth- 
ing is wrong, since he is unable to stop 
thinking about his trouble, and knows quite 
definitely that something is wrong. Neither 
is it profitable to say that the heart is in 
good condition and imply that it is not by 
giving advice regarding exercises or pre- 
scribing tonics. Pseudo-explanations such 
as saying that the precordial sensations are 
due to gas in the stomach pressing up the 
diaphragm and crowding the heart, are also 
to be avoided, for any suggested treatment 
which does not deal with the actual etiology 
of the disorder will cause the patient to 
wander about seeking help, or discourage 
him further and thereby increase his de- 
pression, hypochondriasis and invalidism. 
The physician must be prepared to spend 
sufficient time to be sure of the diagnosis 
and of the actual development of the illness 
in that particular patient. This demand dis- 
courages some physicians since they feel that 
this procedure is too time-consuming. If, 
however, one balances the hour and a half 


February, 1939 


117 


MENTAL HEALTH— EBAUGH 


required for a systematic examination, 
which will facilitate and shorten subsequent 
treatment interviews, against the many 
hours wasted in discouraging glandular and 
sedative medication, it will be seen that the 
long initial interview is entirely worthwhile. 
The anxiety and associated symptoms must 
be thought of as an expression of dysfunc- 
tion of the whole person, and treatment 
should be directed against those factors 
which are the cause. Complete and thor- 
ough physical, neurological, and the neces- 
sary laboratory examinations are done. 
Then attention is paid to the environmental 
factors. If it is necessary and possible to 
change occupational or home situations to 
relieve distress, this should be done. If the 
causal factors are rooted in the personality, 
the need for thorough study of the endow- 
ments and capacities of the person in rela- 
tion to the situation is obvious. The serial 
picture obtained by thorough acquaintance 
with the patient’s problems, assets, liabilities 
and goals suggest specific measures for that 
individual. The general types of these 
measures are known as aeration or ventila- 
tion, suggestion, reassurance, desensitiza- 
tion and reeducation. 

Treatment 

We believe that a few useful sedative and 
hypnotic drugs should be discreetly used, to- 
gether with other adjuncts such as hydro- 
therapy (tubs, packs, sprays, etc.) and ex- 
ercise. We have found that these measures 
help in the establishment of rapport. Bar- 
bital, in 1 to 2 grain doses, given two to 
three times daily, is a useful drug. Spastic 
constipation may be relieved with tincture 
of belladonna, minimus 10-15 given 10 to 
20 minutes after meals. Hydrotherapy is 
extremely valuable for relaxation and im- 
proves muscle and skin tone and general 
metabolism. Unfortunately, continuous 
tubs are not as available as they should be 
in the general hospitals as they are of par- 
ticular value in promoting rest and sedation. 
The patient is usually placed in a tub at 
neutral temperature (96-97° F. ) for one to 
two hours or more daily. Shower baths 
employing warm and cold water at varying 
pressure and cold wet packs may be used. 

It is important to remember that psycho- 
therapy begins with the entrance of the pa- 
tient into the doctor’s office. The long ini- 
tial interview usually has a decidedly bene- 

118 


flcial therapeutic effect, because it instills 
confidence in the patient and points definitely 
to the prospect of relief. With adequate 
examination and explanation the majority 
of anxious patients will usually be able to 
see the real nature of their illness. 

In our experience we have found that if 
the physician will explain the relation of 
the symptoms to the underlying fears by 
giving common examples of visceral partici- 
pation in emotional states such as anger, 
fright or excitement, the patient will not 
concentrate his complaint upon the palpita- 
tion, precordial distress, dyspnea, weakness, 
etc. These symptoms become understand- 
able manifestations of emotions which are 
common to most people. They are not dis- 
regarded as “imaginary” and therefore not 
respectable. 

When explained in a rational manner as 
the natural physiological concomitants of 
an emotional state they lose their ominous 
significance as the possible forerunners of a 
dreaded “insanity.” The diarrhea, polyuria 
and tension during contests or examina- 
tions ; the palpitations, perspiration and 
choking at sudden fright are common exam- 
ples. 

In view of the complexity of a patient’s 
personality and his experiences it will usual- 
ly be found that multiple factors are re- 
sponsible for his illness. If possible, causal 
or contributory situational factors must be 
altered. Frequently the patient must be 
taught to accept certain handicaps or limita- 
tions or to modify his attitude toward them 
so that they are not active sources of con- 
flict. The patient should be kept at his 
regular work if possible. It is always ad- 
vantageous to enlist the aid of the family, 
so that detrimental attitudes and barriers 
to treatment may be removed. If necessary, 
it is well to acquaint the employer with the 
nature of the patient’s illness so that the 
former may lend sympathetic assistance. 
Anxiety syndromes are treatable and the 
simple measures outlined above, when used 
with foresight, sympathy and persistence, 
bring about improvement and recovery in 
the great majority of cases. 

Depression 

DATA WHICH WOULD SUGGEST MANIC 
DEPRESSIVE REACTION 

Sustained alteration of mood, usually in well cir- 
cumscribed attacks. Depressive or elated mood 
or variations such as anger, suspicion, fear, anxiety. 

Jour. M.S.M.S. 


MENTAL HEALTH— EBAUGH 


1. Overactivity (manic). Enterprise, non-restraint, 
extravagance, clash with environment, sexual in- 
discretion. 

a. Increase of psychomotor activity with 
restlessness, ceaseless activity, playfulness, 
facetiousness, inattention to sleep, food or 
care of body. 

b. Push of talk with flight of ideas, rhyming, 
punning, clang association, distractibility. 

c. Exaltation of mood with frequent periods 
of irritability. 

2. Retardation or monotony of behavior and talk 
(depression). Loss of initiative, interest and 
hope. Depression of mood with self-accusation, 
loss of feeling, difficulty in concentration, time 
felt as eternity. 

a. Biological components such as sleep dis- 
turbances (early morning awakening) loss 
of appetite, loss of weight, diurnal varia- 
tion in mood, constipation, loss of sexual 
desire and menstrual disorder. 

b. Modification of content, such as delusions 
of poverty, sin, illness, nihilistic somatic 
delusions, apprehension of impending pun- 
ishment or ruin. 

Billings 1 has shown recently that 20 per 
cent of the cases seen by a Psychiatric Liai- 
son Department in a general hospital, pre- 
sent the fundamental disorder of mental de- 
pression. This is twice the incidence of 
depressions that are admitted to the psycho- 
pathic hospital in the same city (Colorado 
Psychopathic Hospital, Denver). 

The concept of depression encompasses a 
great variety of personality disorders. 5 They 
may include any change in mood from slight 
feelings of discouragement, sadness, futil- 
ity, “the blues,” to the major affective dis- 
orders which constitute separate and at 
times distinct clinical entities: depressions 
in reaction to situations such as death of a 
loved one, illness, personal defeats, financial 
loss, or long-continued stress and strain, 
psychoneurotic depressions, manic depres- 
sive psychoses, involutional melancholia, and 
endogenous depressions associated with 
arteriosclerosis. We are all acquainted with 
the manifestations of the slightly depressed 
mood. With increased depth of depression 
we become acquainted with a number of 
more severe signs and symptoms: decrease 
in activity, dejected facial expression, loss 
of spontaneity of speech and loss of interest. 
Ordinary movements are performed more 
slowly and with heightened effort. The pa- 
tient, in various ways, expresses that he is 
downhearted, miserable, different from 
others and unable to think or concentrate 
as he had before. Complaints of headaches, 
dullness, confusion as well as of constipa- 
tion, loss of taste and appetite, and insomnia 
are very common. In more severe cases the 

February, 1939 


patient will complain of feeling unreal and 
of disorganized function of various organs. 
If concern with bodily function is associated 
with bizarre concepts which may be somatic 
hallucinations or delusions, care must be 
taken to exclude the possibility of a schiz- 
ophrenic reaction, as in some instances an 
initial depressive state may precede its de- 
velopment. 

The depression is differentiated from the 
toxic-organic and the organic groups by the 
absence of sensorial changes. That is, the 
patient is usually retarded or slowed, but 
there is no disturbance of orientation, mem- 
ory, retention, calculation or grasp of gen- 
eral information. At times the depth of the 
delusions interferes markedly with judg- 
ment, as when ideas of personal wrong- 
doing, unworthiness, etc., are prominent. 
Study of the complaint often reveals some 
degree of insight on the part of the patient. 
Paranoid trends may be present. Often the 
mood is one of “impure” depression, that is, 
mixed with feelings of perplexity, irritabil- 
ity and suspicion. Most common is the ad- 
mixture of apprehension with depression. 
Tension, depression and anxiety are fre- 
quent concomitants of somatic disease and 
should be treated by the practitioner with 
the same care that he devotes to the primary 
organic disease. 

Suicide is a constant danger and it is the 
obligation of every physician to watch for 
it and to employ preventive measures. The 
following danger signals may give the phy- 
sician hints of a potential suicidal attempt: 
definite tendency to self-condemnation; ex- 
pression of feelings of futility ; concern over 
the burden to family and friends; desire to 
make a will. When these facts are known 
the physician should employ special precau- 
tions such as having someone in constant 
attendance, removing all sharp instruments, 
medicine, drugs, and as far as possible 
ropes, cords, etc. Previous attempts are to 
be regarded always as serious indications. 
Usually it is necessary to arrange for hos- 
pitalization as an inexperienced personnel is 
totally inadequate to cope with the clever- 
ness of a determined suicide. It is to be 
remembered that many patients commit sui- 
cide during the convalescent period. 

The decision as to whether a given pa- 
tient be treated as a potential suicide is not 
only most difficult but of the greatest im- 
portance. Many depressed neurotic patients 
consider or even speak of suicide by way of 

119 


MENTAL HEALTH— EBAUGH 


“escape,” without seriously contemplating 
it. Here the physician must assume some 
responsibility in minimizing suicide preven- 
tive measures, as their unnecessary use will 
seriously handicap the patient’s recovery. 

Whether a patient is suffering from a 
“true” or symptomatic depression he should 
be placed in a neutral environment free 
from annoyances. Visits from relatives 
and friends should be reduced to a minimum 
as many times they tend to aggravate or 
provoke the patient. Only short, cheerful, 
reassuring visits should be allowed. 

While some of that which follows is de- 
voted to the care of the patient in the hospi- 
tal and thus beyond the usual scope of the 
general practitioner, it is valuable to be 
aware of the principle means of approach. 
In acute phases the physical surroundings 
should be as comfortable, quiet and non- 
stimulating as possible. Probing or investi- 
gative psychotherapy should be avoided. 
Very simple reassurance that mood disorders 
run their course and that the concomitant 
physical complaints are only a part of the 
emotional state is the foundation stone upon 
which the psychotherapy is built. As far as 
circumstances and the patient’s intelligence 
permit, he should be cautiously “reeducated” 
as to his mental state and the danger of re- 
currences thereby diminished. The physician 
should be cautious to avoid premature in- 
crease of privileges, transfer to a more 
stimulating environment or sudden with- 
drawal of sedation. The tactful physician 
will encourage spontaneous discussions with 
the patient, utilizing the patient’s initiative 
and interest as much as possible and avoid- 
ing painful or tabooed subjects until the de- 
pression clears up sufficiently to permit in- 
vestigation. Thus, the material covered in 
these short reassuring interviews should be 
noted by the physician in order that it may 
be employed in future reconstruction of the 
development of the illness. 

The question of when to hospitalize the 
depressed patient is a highly individual one. 
Many mixed depressions are being success- 
fully handled through office interviews all 
over the country. The physician must real- 
ize his responsibility, however, and insist 
upon hospitalization (1) when he detects 
a potential suicide, (2) when the patient’s 
environment mitigates against recoverv, 
(3) when the patient is in danger of estab- 
lishing a narrow, stereotyped behavior pat- 
tern (rut-formation), and (4) when the 


patient becomes a severe nursing problem 
requiring special attention to safeguard his 
health. 

It is obvious that the activities of a pa- 
tient in the hospital can naturally be better 
controlled than at home. In both places, 
however, it is necessary to avoid monotony, 
fatigue and too great expectations. Inas- 
much as the rhythm of a depression varies, 
the physician should constantly avoid “over- 
loading” the patient on those days in which 
he is apt to be discouraged. In our ex- 
perience, walks, handicraft projects, and 
superficial conversation are desirable for the 
more depressed periods. Card games, chess, 
dancing, athletic games and the indoor com- 
petitive games can be utilized for the less 
depressed periods. Rest periods should be 
provided but these should be allowed to in- 
crease without supervision, since rumina- 
tions are fostered by solitary inactivity. 

Close attention should be given to the 
physiologic functions of eating, digestion, 
elimination and sleep. It is necessary to 
keep weight charts and to maintain nutrition 
by urging the patient to eat or, if necessary, 
by employing spoon feeding. Tonics for 
the stimulation of the appetite may be em- 
ployed. Mild cathartics and laxatives are 
preferable to enemas since the latter may 
encourage preoccupation. Depressed pa- 
tients often have an accompanying sleep 
difficulty usually of the early-morning wak- 
ing type. A warm sedative tub of from 1 
to 2 hours’ duration in the evening is often 
helpful in relieving this condition. If ten- 
sion phenomena accompany the depres- 
sion, small doses of barbital given at those 
times throughout the day when the tension 
and depression are at their height are a 
great aid. We have found barbital (grains 
1 to 2) given 2 to 4 times a day very 
useful. Larger doses may lead to dullness, 
headaches and other subjective symptoms 
which add to the patient’s confusion and 
feelings of inadequacy. Paraldehyde is an 
excellent drug for an immediate effect, but 
its taste and odor make it impractical for 
the treatment of mild depressions. We do 
not encourage the use of bromides since 
uncontrolled ingestion leads to toxicity, es- 
pecially in patients with systemic damage. 
It is often necessary to explain in detail to 
patients that the medicines being given them 
are not narcotics, and will not cause true 
addiction with the well known withdrawal 
symptoms. However, it is necessary to keep 
in mind that there is a very real “psychic 

Jour. M.S.M.S. 


120 


MENTAL HEALTH— EBAUGH 


dependence” which is seen in those people 
with personality disorders, who are helped 
to escape disagreeable realities by the use 
of a drug. We need only to cite the ex- 
ample of the various forms of chronic 
alcohol addiction. The physician is respon- 
sible for the complications following the use 
of drugs prescribed by him. He should be 
able to recognize the toxic symptoms accom- 
panying prolonged usage or overdosage. 
The dosage should be reduced frequently in 
a consistent attempt to divorce the patient 
from his “crutch.” It is desirable that pa- 
tients who are in the hospital be independent 
of sedative medication before they are dis- 
charged. 

The preceding account has been all too 
brief and special therapeutic procedures 
were not considered, but if the practitioner 
will utilize the principles laid down, he will 
find that he will be able to handle these 
cases with more assurance and with greater 
success. 

Schizophrenia 

DATA WHICH WOULD SUGGEST 
SCHIZOPHRENIC REACTION 

a. Shut-in, seclusive personality with a tendency 
to live in phantasy. 

b. A development toward odd or impulsive be- 
havior, increasing preoccupation. 

c. Evidence of loss of the boundaries between self 
and the outside world, running together of day 
dreams and historical facts. 

d. Auditory, visual and somatic hallucinations 
Ideas of influence, reference and persecution ; 
phantastic symbolization. 

e. Persistent bodily concern of a bizarre quality. 

f. Incongruity of affect and content, inadequate 
blending of preference and aversion, indifference. 

g. Indecision and puzzling; scattering and block- 
ing. 

h. Motility disturbances such as posturing, mim- 
icking, grimacing. 

Time will not permit a detailed discus- 
sion of the varying concepts of schizo- 
phrenia, its economic and social significance 
nor the attention attached to it by the claims 
of the recently introduced shock treatment. 
However, an outstanding fact is the revela- 
tion that most patients suffering from this 
illness are brought to hospitals at an aston- 
ishingly late stage. Although the illness is 
one with a relatively low incidence it has 
great chronicity, so that ultimately more 
hospital beds are occupied by schizophrenic 
patients than by patients suffering from any 
other mental illness. That this imposes a 
heavy financial burden on the community is 
obvious to all of us. 

It is significant that the average patient 
February, 1939 


is brought to the hospital relatively late 
in his illness. For example, in many in- 
stances when hospital treatment is begun, 
symptoms have been present for years. If 
for no other reason than that of recogni- 
tion, it behooves the general practitioner to 
know and understand some of the early 
presenting signs and symptoms. It is to be 
understood that the following symptoms as 
noted by Cameron 2 are by no means exclu- 
sive to schizophrenia, nor in any way path- 
ognomonic of the disorder. They are com- 
plaints or symptoms which are found fre- 
quently in association with schizophrenia 
and may signal the onset of a more malig- 
nant disturbance. 

“In the younger age groups there are two fairly 
well divided trends. In one, there is a slow and 
gradual evolution of schizophrenia in a person who 
has from childhood been shy, retiring, odd, some- 
what aloof or one who has showm many behavior 
problems such as temoer tantrums, long standing 
enuresis and emotional instability. In instances 
such as these there is a gradual accentuation of 
personality deviation. These patients are rarely 
recognized before the onset of frank delusional 
symptoms. 

In another manner of development of the younger 
age groups, the patient, who may have experienced 
some stress, reacts in an odd or dramatic way which 
may take the form of stupor, excitement, bizarre 
forms of exhibitionism, confusion, et cetera. 2 ” 

In the older age groups, the onset is more* 
insidious. There are a number of symptoms 
which require our special attention. You 
will remember that we enumerated a num- 
ber of symptoms which would suggest a 
schizophrenic reaction. The following are 
reiterated in an attempt to emphasize their 
frequency and importance. 

1. Withdrawal from reality, with con- 
siderable daydreaming, narrowing of inter- 
ests, active effort to gain solitude. 

2. Loss of capacity with difficulty in 
concentration, loss of ambition, occasional 
exhibition of poor judgment and decreased 
adjustment capacity. 

3. Emotional dulling with disinterest, 
callous behavior and inscrutability. 

4. Tendency to misinterpretation with 
early ideas of reference; belief that people 
are unfriendly, etc. 

5. Difficulty in thinking with symptoms 
of theft of thought, intrusion of thoughts, 
etc. 

6. Physical ailments, with hypochron- 
driacal preoccupation, sometimes leading to 
somatic hallucinations. 

7. Feeling of unreality with loss of iden- 
tity, change in self, etc. 


121 


MENTAL HEALTH— EBAUGH 


The differential diagnosis of this illness 
presents a number of problems. The dif- 
ferentiation from the somatic disturbances, 
such as cranial neoplasms, epilepsy, post- 
encephalitic disorders, and the toxic states 
usually does not present any great difficulty. 
In the latter the involvement of the in- 
tellectual faculties without a primary dis- 
turbance of the affect stands out in contrast 
to the thinking and emotional disorders of 
the schizophrenic. The greatest difficulty 
will be had in the differentiation of certain 
types of manic depressive insanity and the 
obsessional types of the neuroses. How- 
ever, a thorough scrutiny of the pre-morbid 
personality as well as study of the develop- 
ment of the illness and the presenting signs 
and symptoms should enable the physician 
to recognize the fundamental personality 
disorder of the schizophrenic. 

The voluminous literature on the treat- 
ment of the schizophrenic is evidence of the 
numerous difficulties of this problem and of 
the uncertainty in its solution. We may 
safely say that we know of no specific cure. 
Recently, two modes of pharmacological 
shock treatment have been introduced, 
namely, insulin shock and metrazol convul- 
sion therapy. It is too early to comment 
with any degree of certainty or accuracy 
on the therapeutic efficacy of these methods. 
However, I do not believe that the solution 
to as complex a problem as schizophrenia 
is going to be purely physico-chemical. The 
complexity of the structure of personality, 
both healthy and sick, with its somatic, per- 
sonal and interpersonal factors, needs an 
analysis that must be pluralistic in scope and 
constantly aware of man as a functioning 
physiologic, psychologic and social unit. It 
is not within the scope of this paper to 
consider the many therapeutic attempts of 
the past. Suffice it to say, that early recog- 
nition should be within the ability of the 
general physician, that care be taken to 
avoid detailed probing investigation, that 
the asocial and anti-social trends of the pa- 
tient be understood and that special aid be 
requested as early as possible. 

Toxic — Organic 

DATA WHICH WOULD SUGGEST THE TOXIC 
ORGANIC REACTION TYPE 

(Delirious reactions, symptomatic psy- 
choses) 

1. Primary disturbance in the level of awareness 
(consciousness) . 

2. Secondary elaboration of fear, anxiety, delu- 
122 


sional and hallucinatory phenomena (usually 
visual). 

3. Physical and laboratory evidence of cardio- 
vascular failure, anemia, avitaminosis, intoxica- 
tion by sedative drugs, alcohol, heavy metals- 
infection, and postoperative states. 

The general practitioner sees a goodly 
number of mental disorders complicating 
other diseases. These are sometimes called 
symptomatic psychoses, toxic organic reac- 
tions, the exogenous reaction types, mental 
symptoms in somatic ailments and the de- 
lirious reaction types. 

They are characterized by a disturbance 
of the level of consciousness or awareness 
which may vary from slight inattention to 
profound coma. The secondary super- 
structure of fear, with delusional and hallu- 
cinatory trends is colored individually by 
the personality of the patient. They are 
closely connected with somatic conditions in 
that they are dependent upon, or associated 
with, intoxications by drugs or poisons, nu- 
tritional disturbances, circulatory phenom- 
ena and metabolic disorders. These dis- 
turbances produce temporary brain changes 
which are in the nature of edema or the 
obscure concomitants of fever and acidosis. 
The occurrence of delirium should not be 
considered merely incidental to the principal 
disease picture. It is a complication that 
may, and in a great percentage does, inter- 
fere with the treatment of the presenting 
clinical problem. To say the least, it in- 
creases the suffering, prolongs the duration 
of the illness and may necessitate special 
hospitalization of the patient. It may even 
be a disorganizing factor of such magnitude 
as to produce chronic invalidism and incom- 
petency. A very large percentage of deliria 
either are preventable or can be ameliorated 
if recognized early. 

It will not be necessary to recount the 
characteristic signs and symptoms as they 
have been noted previously. 

Etiologically the deliria may be grouped 
as follows: (1) those due to exogenous 
poisons such as alcohol, opiates, bromides, 
marihuana, barbiturates, et cetera; (2) 
those due to chronic cachectic states; (3) 
those due to malnutrition, deficiency dis- 
eases and metabolic disorders; (4) those 
occurring as a part of an “organic reaction’’ 
such as in paresis or cerebral arterioscle- 
rosis. 

The general facts relative to a delirious 
reaction as elicited on indirect examination 
(history of the illness from all sources), 

Jour. M.S.M.S. 


MENTAL HEALTH— EBAUGH 


reveal that the onset of the condition usually 
is quite sudden and frequently makes its ap- 
pearance at night, or when the patient’s sur- 
roundings are changed. This onset is char- 
acterized by objective evidence that the pa- 
tient is misinterpreting sounds, conditions 
and occurrences in his environment, has 
dream-like fancies and hallucinations and is 
partially or completely disoriented. The 
hallucinations usually are vivid and most 
frequently involve vision and hearing, al- 
though the skin may also be involved. If 
these symptoms are not foremost, then the 
restlessness of the patient, his tendency to 
leave his bed and wander away and his re- 
action of annoyance, irritation or fright 
may signal the beginning of such a reac- 
tion. 

From the foregoing it can be seen that 
the treatment of the toxic psychoses re- 
quires knowledge of the whole domain of 
general medicine. Specific therapeutic meas- 
ures will be dictated by the type of infec- 
tion or poisoning which is the basis of the 
psychosis. It may be wise, however, to 
consider certain general principles, which 
are applicable in the majority of cases. 

(1) Careful eliminative procedures are 
fundamental. Among these are catharsis, 
gastric lavage, attention to the fluid balance 
of the body and urinary excretion. 

(2) An attempt to control infection 
should be made as well as to eliminate foci 
of infection. 

(3) The efficiency of the “support sys- 
tems” should be bettered. Cardiac stimu- 
lants and regulators should be utilized in 
case of actual or even threatened cardiac 
decompensation. 

(4) Dehydration and acidosis must be 
minimized and controlled. Routine dietetic 
and tonic treatment is required in the man- 
agement of the majority of the reactions in 
this group. Transfusions are indicated if 
the hemoglobin value is below 50 per cent. 
They are extremely valuable and may be 
life saving in hemorrhage, secondary ane- 
mia, infectious diseases, shock and certain 
poisonings (carbon monoxide, acetanilide). 

(5) If cerebral edema is present, spinal 
drainage and the cautious intravenous ad- 
ministration of hypertonic glucose or su- 
crose are indicated. 

(6) Sedation and its proper application 
with full appreciation of its dangers is im- 
portant. Sedatives are of value in that they 
enable the patient to rest but they should 

Ferruary, 1939 


never be given for the sake of convenience 
in nursing care. Hydrotherapy and/or 
chemical sedation may be employed. As 
stated previously, the most helpful of the 
hydrotherapeutic measures is the continuous 
or neutral tub. The temperature of the 
water should range from 97.6° (in case of 
fever) to 99° F. Care must be taken to 
keep the temperature in the tub room con- 
stant. The patient may be kept in a con- 
tinuous tub for one to twenty-four hours 
without difficulty. The time element is de- 
pendent upon the effect desired and the 
patient’s physical status. It is well known 
that the vegetative nervous system appa- 
ratus of the delirious patient usually is un- 
stable and therefore, shocks in the form of 
cold water must be avoided. For this rea- 
son as well as the need to avoid restraint, 
packs are usually contraindicated. 

Hypnotic drugs should not be given dur- 
ing the day but they are permissable at 
night. The choice of drug is dependent 
upon the type of delirium and the causal 
toxic agent. In general, a quickly acting, 
rapidly metabolized and eliminated drug, 
such as paraldehyde is indicated. We be- 
lieve that paraldehyde has the greatest mar- 
gin of safety, and is easily and rapidly elim- 
inated. The offensive taste and odor may 
be disguised by preparing it in iced lemon 
or grape juice for oral administration. It 
may be administered rectally in mineral oil. 
It is important to give the hypnotic in a 
large enough dose to cause sleep and should 
be administered before darkness, since the 
latter is prone to increase the patient’s dis- 
orientation and fear. The problem of seda- 
tion is a very important one, inasmuch as 
there is a tendency to use drugs indiscrimi- 
nately and promiscuously. If care will be 
taken to avoid overdosage and to recognize 
sensitivity, for example, to the barbiturates, 
a great many toxic reactions caused by 
chemical sedation may be avoided. 

(7) The nursing care is worthy of a 
great deal of careful consideration and re- 
quires understanding, ingenuity and skill. 
The patient must continually be reassured 
as to the intentions of the nurses and phy- 
sicians. Furthermore, the management of 
the environment with the elimination of dis- 
concerting shadows, sounds and movements, 
is necessary for the comfort and progress 
of the patient. He should be safeguarded 
from accident and suicide during the acute 
manifestations of the psychosis. 


123 


MENTAL HEALTH— EBAUGH 


(8) It is valuable to note in detail the 
behavior and verbal production of the delir- 
ious patient as these may aid in the eventual 
analysis and reeducation of the personality. 
In this respect, the use of more specific 
psychotherapy should begin during the con- 
valescence. 

(9) Last, but certainly not least, a word 
for prevention. Although it is true that 
medical men usually are not called until the 
delirium is “full blown,” the surgeon often 
has it within his power to prevent and con- 
trol these reactions. One need only men- 
tion adequate preparation for the operative 
procedure, cautious use of basal and other 
anesthesia, judicious postoperative care 
avoiding oversedation, toxicity and dehydra- 
tion to be aware of the various preventive 
aspects of the problem. 

Organic Reaction Types 

DATA WHICH WOULD SUGGEST THE ORGANIC 
REACTION TYPE 

1. A long record of effective life performance, 
followed by a striking decline with character 
and personality change. 

2. Evidence of impairment of the sensorium (dis- 
turbances of memory, retention, judgment, etc.). 

3. Neurological and serological evidence of in- 
volvement of the central nervous system. 

Proceeding, then, to the organic reaction 
types, we meet the various clinical syn- 
dromes with which most of you are fami- 
liar. In almost all of these conditions, a 
definite organic lesion is present, and this 
lesion, if recognized, gives the physician 
a tangible explanation for the accompanying 
personality changes. In general, the or- 
ganic reactions are characterized by chronic-- 
ity of course. They are dependent upon 
focal or diffuse, more or less permanent 
and intrinsic changes in the central nervous 
system. Obviously, transition states may 
exist between the delirious and the organic 
reactions types. Causally, the latter are 
associated with organic toxins, metabolic 
disturbances, syphilis, arteriosclerosis, ne- 
oplasm, trauma, senility, certain of the epi- 
lepsies, eclampsia and organic residuals of 
meningitis and encephalitis. While the clin- 
ical picture varies from case to> case, and 
the etiology and duration of the diseases 
differ, the characteristic features of this 
type of disorder are as follows: 

(1) A definite organic change exists in 
the central nervous system. This may be 
in the nature of nutritional disturbance, 
neoplasm, inflammation or degeneration. 


The motor and sensory reflexes are often 
disturbed, and these disturbances may lead 
to derangements of speech and equilibrium 
and to difficulty in writing and walking. 
Special laboratory and clinical procedures, 
such as the study of eye grounds, perimetry, 
spinal fluid, encephalography and ventricu- 
lography, are of value in the diagnosis of 
these conditions. 

(2) Personality changes are striking 
and are reflected both in the deterioration 
of ethical feelings and in the development 
of behavior patterns inconsistent with the 
individual’s former habits. For example, a 
respectable person may become vulgar and 
obscene, and a frugal, conservative indivi- 
dual, extravagant and grandiose. On the 
other hand, the symptoms may represent 
an accentuation of the normal constitutional 
makeup. Thus, paranoid forms of senile 
deterioration may develop in persons who 
have always been suspicious and distrustful, 
and paresis may have a depressed or manic 
coloring, somewhat in accord with the pa- 
tient’s previous reaction pattern. 

(3) The affect is characterized by emo- 
tional instability with marked fluctuations 
in the mood. Thus, the individual may ex- 
hibit almost mercurial changes from joy to 
sorrow and back again. 

(4) Mental changes are quite character- 
istic and result in a decline in the patient’s 
business and intellectual efficiency. Periods 
of confusion, fluctuations in the level of at- 
tention, with memory loss, disorientation, 
lack of comprehension, disturbance of judg- 
ment and even delirious states are common. 

(5) A great number of these reactions 
are preventable. Particularly in relation- 
ship to the central nervous system forms of 
syphilitic invasion. 

(6) The prognosis varies and is depen- 
dent upon the causal factors, but, in general, 
is poor. 

Time will not permit a detailed account 
of the treatment of the organic psychoses, 
but it will suffice to say that therapy should 
consist of two approaches. The first or 
direct should be directed towards the causal 
agents, if possible. For example, the treat- 
ment of the syphilitic psychoses should con- 
sist of some form of hyperpyrexia, together 
with or followed by arsenical chemotherapy. 
The treatment of an organic psychosis due 
to a cranial neoplasm should be the removal, 
if possible, of the tumor. 

The second or indirect phase of treatment 

Jour. M.S.M.S. 


124 


FEVER OF UNDETERMINED ETIOLOGY— SMITH 


is directed toward the alleviation of symp- 
toms. This usually consists of cautious seda- 
tion, hydrotherapy, reeducation, and, if 
necessary, hospitalization. 

Conclusion 

I am very happy to have had this oppor- 
tunity of welcoming the prospect of a closer 
union between psychiatry and general medi- 
cine. I feel that the mutual benefits of such 
a relationship will improve the standards 
of medical practice. 

I have stated that the obligations of the 
medical profession in relation to mental 
health are two in number. The first, direct, 
positive or preventive aspect is that of 
knowledge of self in an attempt to gain 
mental health for one’s self. The second, 
indirect or negative phase is that of the rec- 
ognition, interpretation and treatment of the 
various personality disorders that come to 
the attention of the general practitioner. 
A plea is made for the better understanding 
of attitudes and facts in mental illness so 
that the general practitioner can gain a 
more wholesome way of life for himself, as 
well as enabling him to care for the many 
personality problems that come to him for 
aid. We must keep in mind that the gen- 


eral practitioner is on vantage ground. It 
is he who is intimate with the family of the 
patient, who constantly observes the family 
situations, who knows the strong and weak 
components of the personality of the patient, 
and to whom the family turns first for help. 
For these reasons the general practitioner 
is in a position to make a genuine and last- 
ing contribution to the mental health of a 
community. 

References 

1. Billings, E. G. : The general hospital, its psychiatric 

needs and the opportunities it offers for psychiatric 
teaching. Am. Jour. Med. Sci., 194:234, (August) 
1937. 

2. Cameron, D. Ewen : Early diagnosis of schizophrenia 

by the general practitioner. New Eng. Jour. Med., 
218:221, (February 3) 1938. 

3. Ebaugh, F. G. : Class A. Standards for the Teaching 

of Psychiatry. Proceedings of the Second Conference 
on Psychiatric Education, pp. 125-131. National Com- 
mittee for Mental Hygiene, 1935. 

4. Ebaugh, F. G. : The crisis in psychiatric education. 

Jour. A.M.A., 99:703, (August 27) 1932. 

5. Ebaugh, F. G. : Frequent psychiatric complications in 

general practice. Am. Jour. Med. Sci., 194:243, (Au- 
gust) 1937. 

6. Kanner, Leo: “Psychopathological Problems of Child- 

hood,” “Practical Clinical Psychiatry,” by Strecker and 
Ebaugh, Fourth edition, Philadelphia: P. Blakiston’s 

Son & Co., Inc., 1935. 

7. National Committee for Mental Hygiene, Mental Hy- 
giene Bulletin, (January-February) 1931. 

8. Raphael, Theophile : Psychoses among College Stu- 

dents. Read at the Ninety-Fourth Annual Meeting of 
the American Psychiatric Association, San Francisco, 
California, (June 7) 1938. 

9. Ryan, W T . Carson : Mental Health Through Education. 

New York: The Commonwealth Fund, 1938. 

10. White, William A. : Twentieth Century Psychiatry. 

New York: Norton, 1936. 


FEVER OF UNDETERMINED ETIOLOGY* 

DONALD S. SMITH, M.D. 

PONTIAC, MICHIGAN 

This study was undertaken as a result of observation of a number of cases followed 
over a long period of time in which all diagnostic studies failed to give us a positive 
diagnosis. The problem of long lasting unexplained fever is of great importance to 
physicians and patients. All internists must frequently be faced with it. In many in- 
stances the height of the fever and other changes such as leukocytosis make it apparent 
that there is an organic cause for the fever and the problem is to identify the cause. In 
other instances the fever is of low grade, it persists for months and sometimes for years 
without organic cause becoming evident and 
it is associated with various symptoms and 
findings suggestive of psychoneurosis so 
that even the possibility of a psychogenic 
origin of the fever has been considered. 

The possibility of fever being of psycho- 
genic origin has been advanced by numerous 
authors, while others believe that a type of 
so-called “habitual hyperthermia” exists. In 
1912 Moro 9 first spoke of a group of cases 
where fever was present after exertion. 

*From the Department of Internal Medicine, University 
of Michigan Medical School, Dr. C. C. Sturgis, Director. 

Read before the medical section of the Michigan State 
Medical Society, Detroit, September, 1938. 

February, 1939 


Dresel 4 states that we have to presuppose 
that the behavior of temperature is just as 
variable from person to person as blood sug- 
ar, blood pressure and other physiological 
constants. He believes that one is dealing 
with sympathetic and parasympathetic vari- 
ability which is possibly from a central ori- 
gin. Egger 5 noticed vasomotor neurosis 
with small elevations in a psychopathic indi- 
vidual. Briinecke 2 believes that a habitual 
fever exists but is so rare that a given in- 
dividual will rarely see it if all diagnostic 


125 


FEVER OF UNDETERMINED ETIOLOGY— SMITH 


criteria are exhausted. In cases of this 
type he believes that other stigmata of con- 
stitutional inferiority are present as derma- 
tographia, excessive sweating, and psychic 
symptoms suggesting neuroses. Jahn 7 be- 
lieved there were two principle theories of 
psychogenic fever, namely, vasomotor proc- 
esses and direct influence on heat cen- 
ters of the brain. He found this sub- 
febrile state to be most prevalent in wom- 
en and the prognosis was very good in 
the cases observed. Cawadias 3 also observed 
cases of this type and believed a definite 
syndrome existed with low grade fever, 
emotional instability, and vasomotor dis- 
turbances. He also believed that this condi- 
tion was not one of infection and more espe- 
cially not tuberculosis. 

In 1930 Alt and Barker 1 presented a large 
series of this type of cases in which they 
found 23 per cent developed organic disease 
with approximately 6 per cent each of 
tuberculosis and rheumatic heart disease. 
Kintner and Rowntree 8 in 1934 observed a 
group of cases which they believed fell in 
a group of neurogenic or psychogenic 
fevers. They believed that it might be a 
disease “sui generis” which has not yet been 
investigated thoroughly enough. Proger 
and Falcon-Lesses 6 previous to this had 
presented one patient on whom they had 
made careful observation demonstrating the 
existence of a fever which they believed 
to be related to psychic upsets. Reimann 10 
in 1932 presented a case of persistent fever 
of nineteen years’ duration for which no 
organic disease was discovered as the cause. 

We have reviewed the cases discharged 
from the University Hospital during the 
past ten years in whom the final diagnosis 
was fever of unexplained etiology. We 
have also reviewed the cases in whom the 
major diagnosis was psvchoneurosis but 
who were known to have had fever of long 
duration. The size of the series would have 
been greatly increased if we had also in- 
cluded those who had low grade fever while 
under observation, the occurrence of which 
had not been previously known. Such cases 
are frequent and they seem clinically cpiite 
similar to those studied. For this study 
we excluded cases with fever of less than 
one month’s duration, those whose fever 
subsided during observation although not 
diagnosed, postoperative cases with fever, 
and children under fourteen years of age. 

126 


After these restrictions were made there 
remained seventy-five cases. Of these we 
were able to obtain satisfactory follow-up 
information in fifty-one cases, some by re- 
examination, some by information from the 
local physician, and some by questionnaire. 

Analysis of Material 

In our series of fifty-one cases with fol- 
low-up information we found seven cases 
with definite septic type of fever and two 
cases with high fever who were later found 
to have had neoplasms. In these nine pa- 
tients, the duration of the fever before ad- 
mission ranged from two to eighteen 
months, averaging 8.8 months. The height 
of the fever was from 101° to 106 c F. 
There were abnormal blood findings in all 
these cases, five having a leukocytosis, six 
having elevated sedimentation rate, and six 
having secondary anemias. The average 
duration of fever after discharge was four 
to twelve months, averaging 7.8 months. 
Eight patients in this group had definite 
localized pain which could not be adequately 
explained. Four complained of joint pains 
and a similar number had chills and fever. 

Of these patients six are dead and three 
still living. Two developed neoplasms, two 
liver abscess, subphrenic abscess in one, em- 
pyema of the gall bladder in one, septicemia 
one, embolic nephritis one, chronic pneumo- 
nitis one. Of the two neoplastic deaths, 
one was a primary renal neoplasm and the 
other neoplastic involvement of the hip. In 
every case in this group, there was adequate 
evidence at the time of the original exam- 
ination to suggest a diagnosis of either ne- 
oplasm or sepsis, but the location and type 
could not be determined. 

A second group of patients, four in num- 
ber, later developed symptoms of arthritis. 
The fever had been present for an average 
of twenty-seven months before admission. 
The fever ranged up to 101. There was a 
mild secondary anemia present in two cases. 
The fever persisted for three to thirty 
months, averaging fifteen months after dis- 
charge. Two of these patients developed 
migratory arthritis and two rheumatoid 
arthritis. Our follow-up in these patients 
averaged forty months. The original 
symptoms are of interest since only one pa- 
tient had joint symptoms. Nervousness 
and ease of fatigue were present in three. 

There were three patients in this series 

Tour. M.S.M.S. 


FEVER OF UNDETERMINED ETIOLOGY— SMITH 


who presented more severe complaints of a 
nervous nature such as gagging, marked ease 
of fatigue to the extent of incapacitating 
the patient and so-called “nervous break- 
down” symptoms. The fever had been 
present from one month to ten years before 
admission in these cases. The height of the 
fever ranged from 99.8° to 100.4° F. An 
elevated sedimentation rate was found in 
one case. The fever persisted after dis- 
charge for six months to two years. The 
final diagnoses were schizophrenia in two 
cases, and one suicide. 

There is a rather large group of patients 
with unexplained fever over one month 
duration which may be attributed to infec- 
tion, acute or subacute. In this series there 
were thirteen such cases. The fever was 
noted for intervals ranging from one to 
thirty-six months, averaging seven months. 
The height of fever was from 101° to 103° 
F. In seven cases the blood was abnormal, 
five showing leukocytosis, four secondary 
anemia, and in seven an elevated sedimenta- 
tion rate. The fever persisted after dis- 
charge an average of 5.5 months. The 
symptoms were variable, many of them 
directly attributable to low grade infection. 
There were pains in the abdomen in five, 
chills and fever in three, nervousness or 
weakness in six, and pain in the chest in 
two. Chest radiographs gave negative find- 
ings in all cases. In only three was a diag- 
nosis definitely established, one having a 
kidney stone removed later, one having bru- 
cellosis and one having a chronic appendix. 
The renal stone and chronic appendix did 
not adequately explain their symptoms at 
the time of our observation. The average 
length of follow-up in these cases was two 
and one-half years. At the end of this pe- 
riod all these cases were well. We were 
forced to conclude in these patients there- 
fore, that there was evidence of infection 
at the time of our observation and that it 
subsided spontaneously in all of them with 
the exception of the operated cases. 

By far the largest group of cases was 
those running a low grade fever over longer 
periods of time. In this series there were 
twenty-two cases of this type. The fever 
had been present three months to thirteen 
years, averaging 3.8 years before admission. 
The temperature had never gone over 100° 
F. The blood findings were normal in every 
case. The fever persisted from two months 

February, 1939 


to ten years after discharge, averaging 
three years. Our follow-up information 
averaged 3.8 years in these cases. The 
symptoms found in these patients were 
chiefly neurasthenic in type, ten having ease 
of fatigue, seven chest pain, six weakness, 
five having effort syndrome symptoms, and 
four complaining of emotional upset and a 
like number of the fever itself. Three of 
these patients complained of difficulty in 
swallowing, suggestive of globus hystericus. 
Chest radiographs and all other studies bv 
various departments were entirely negative. 
All these patients were well at the time of 
completion of this study. No disease was 
discovered in this group of patients at the 
time of our original examination nor has 
any developed in the period of our follow- 
up. 

Presentation of Cases 

It would appear worthwhile to analyze 
in detail a case or two from the last group. 

A young woman, aged seventeen, was admitted 
to the University Hospital complaining of continu- 
ous fever and weakness of one year’s duration. She 
had noted ease of fatigue and low grade fever, 
99.8° and 99.4° on many occasions. There had been 
a weight gain of ten pounds. Complete examination 
was negative including chest radiograph. Intra- 
dermal tuberculin and brucellin skin tests were neg- 
ative. The erythrocyte sedimentation rate was 0.29 
millimeters per minute which is well within normal 
limits. The blood examination revealed no abnor- 
malities. The urine examination was entirely neg- 
ative. One year later this patient still had temper- 
ature elevation to 99.4° F. and had developed no 
organic disease. 

A second patient, a woman, aged twenty-seven, 
was observed at the University Health service from 
1930 to 1934 for unexplained fever. During this 
time her temperature ranged up to 100°. All 
studies at that time were negative including chest 
x-rays on multiple occasions. Ten months previous 
to our examination she had been studied at the 
Massachusetts General Hospital for fever of 2 
months duration. She came to the University Hos- 
pital in 1935 complaining of ease of fatigue and 
cough. The exacerbation of symptoms had begun 
2 months previously with an upper respiratory in- 
fection and since then had continued to run a 
low grade fever. Our studies showed negative 
chest x-ray, negative agglutination series, and neg- 
ative physical and blood examinations. The sedi- 
mentation rate was well within normal limits. The 
fever had apparently been present at all times from 
1930 to 1935 while the patient was in perfect health. 
We were forced to conclude that there was no 
organic basis for the fever in this case. 

A third patient, a woman aged thirty-eight, was 
first seen in the University Hospital in 1931 com- 
plaining of “indigestion.” A temperature elevation 
of 99.4° was noted then. All studies were nega- 
tive ; the final diagnosis was psychoneurosis. In 1932 
she was observed at the Mayo clinic where the tem- 
perature was 99.4° and all studies were negative; 
they concluded that there was no disease present. 
In 1933 she was studied at Crile Clinic where the 

127 


FEVER OF UNDETERMINED ETIOLOGY— SMITH 


temperature was recorded at 99.8° and again no 
diagnosis was made. In 1936 she again entered the 
University Hospital complaining of excessive sweat- 
ing and ease of fatigue. She had been confined to 
bed since 1933. All of our studies were negative 
with the exception of the sedimentation rate, which 
varied from 0.52 to 1.13 millimeters per minute, 
definitely elevated. The temperature at this time 
varied from 99° up to 100°. We concluded that 
this patient might temporarily have a low grade 
infection which was subsiding at the time of our 
observation as evidenced by the sedimentation rate, 
but that the chief diagnosis was psychoneurosis. In 
1938 this patient developed definite ideas of persecu- 
tion and other manifestations of schizophrenia. 

Discussion 

In the first group of cases it would seem 
obvious that these patients had, for the most 
part, infection, type and location not deter- 
mined at the time of our observation. The 
presence of fever over 101° in all cases, 
leukocytosis or secondary anemia in the 
majority of them, and an elevated sedimen- 
tation rate was found. These cases are 
apparently the type that defy diagnosis by 
the methods at our disposal at present, yet 
the diagnosis of sepsis would seem to be in 
order. 

In the second group of four cases, we 
find a period of one year elapsing before a 
diagnosis of arthritis was made. The prob- 
ability is suggested that the rheuamtic state 
was the cause of the fever from the begin- 
ning. It is well known that rheumatic 
heart disease occurs in many people who 
have never had arthritis. Four of Alt and 
Barker’s 1 cases of unexplained fever were 
subsequently found to have definite valvular 
heart lesions and two others developed pre- 
sumptive evidence of rheumatic infection. 
Also many cases of clinical rheumatic fever 
recover and never develop evidence of a 
valve lesion. However, it seems certain 
that some of the cases of undiagnosed fever 
that never develop arthritis or a valve lesion 
have rheumatic infection. How many, 
must remain a matter of speculation until 
the etiology of rheumatic infection is posi- 
tively determined and laboratory diagnosis 
in the active stage becomes possible. 

There is a rather large group of cases 
in whom the infection subsides in a short 
time and yet no diagnosis can be established. 
Part of these cases undoubtedly fall into the 
rheumatic group. All studies such as in- 
vestigations regarding foci of infections, 
x-rays where indicated, blood and stool cul- 
tures were carried out on these patients and 
yet no diagnosis could be reached. W e did 


not have the brucellin skin test performed 
on many of them but the agglutination 
series were done. It is known that negative 
agglutination tests for undulant fever do 
not rule out that condition but that the 
phagocytic index together with the brucellin 
skin test are of definite diagnostic value. It 
is unfortunate that in the majority of our 
cases the phagocytic index and skin test 
were not done. It is possible that a few of 
these patients may have been subclinical 
cases of brucellosis but we were unable to 
prove this diagnosis. The same is true of 
the tuberculin test; while chest x-rays were 
taken on all our cases, the tuberculin skin 
test was not performed. It is felt that a 
negative tuberculin test would definitely be 
of value. 

The erythrocyte sedimentation rate has 
been found to be a rather accurate index of 
tissue destruction either in neoplasm or in- 
fection. It is very unusual to see a normal 
sedimentation rate in a chronic infection. 
In the group of cases with infection, the 
sedimentation rate was elevated in all cases 
in which it was done. It is our feeling 
that the sedimentation rate is the best index 
of the presence or absence of infection. 

In twenty-two cases there was no objec- 
tive evidence of pathology at the time of 
observation and none has subsequently de- 
veloped over periods varying from one to 
ten years. In this group every apparently 
indicated study was carried out with the 
exception of the brucellin skin test and the 
sedimentation rate, which was not done in 
some, chiefly in the earlier cases. Radio- 
graphs of the chest were made in all cases on 
one or more occasions. Where there were 
any gastro-intestinal complaints a radio- 
graph was taken and stool examination and 
culture were carried out. Most of the pa- 
tients in this group were seen by a psychia- 
trist, who diagnosed psychoneurosis in the 
majority of them. It is of interest that, in 
cases where the temperature was taken in 
the follow-up period, fever continued in 
all except one case. In this case the com- 
paratively short period of fever before and 
after observation, five months and two 
months respectively, suggests the probabil- 
ity of an organic cause, of which the sedi- 
mentation rate might have given evidence. 
The duration of fever before our observa- 
tion (average 3.8 years) and its length in 
the follow-up (average three years) would 
seem to be sufficient time for any organic 

Jour. M.S.M.S. 


128 


SULFANILAMIDE — ENGELFRIED 


cause to become evident or for fever due to 
most such cases, to subside. We are inclined 
to agree with those who believe that fever 
can be of psychogenic origin and to classify 
these patients under this diagnosis. 

Although such a classification of these 
cases seems in retrospect quite justifiable, 
the problem of the individual case with low 
grade fever which is not known to be of 
very long duration is quite different. It is 
probably an unusual coincidence that, in this 
series, almost all of the cases that were ulti- 
mately considered to have an organic cause 
for fever had evidence of such a cause in 
a temperature of 101° or higher, leukocyto- 
sis, or increased sedimentation rate. * It 
would seem, however, that a patient with 
fever who does not have these findings and 
in whom thorough diagnostic studies have 
been negative can be given considerable as- 
surance. In such a case, periodic reexami- 
nations and appropriate symptomatic treat- 
ment is indicated but it is unlikely that 
serious organic pathologic changes will be- 
come apparent. 

Conclusions 

1. Fever of unexplained origin resolves 
into four classes of patients: 

(1) Those with infection, type and lo- 
cation not determined. 

(2) Those with neoplasms, origin not 
apparent. 

(3) Those with rheumatic infections. 


(4) Those whose fever may possibly be 
psychogenic in origin. 

2. The recognition of psychogenic fever 
is exceedingly difficult and such a diagnosis 
should be considered only after a prolonged 
and thorough period of observation. 

3. In our opinion the sedimentation rate 
is a valuable diagnostic procedure in dif- 
ferentiating infection fevers from question- 
able psychogenic ones. 

4. If a patient has absence of all or- 
ganic findings and a normal sedimenation 
rate it is thought inadvisable to make a 
chronic invalid of the patient or to remove 
non-diseased organs such as appendix, ton- 
sils, and gallbladder. 


The author wishes to express his sincere apprecia- 
tion to Dr. Henry Field, Jr., for the many helpful 
suggestions and careful guidance in preparation of 
this paper. 

References 

1. Alt, H. L., and Barker, M. H. : Fever of unexplained 

etiology. Jour. A. M. A., 94:1457, (May 10) 1930. 

2. Brunecke, Kurt: tfber Habituelle Hyperthermie. Beitr. 

z. Kliuik d. Tuberculose, 63 :412, 1926. 

3. Cawadias, Alex. : Continuie Fievre d’Origine Svm- 

pathique. Annal de Medicini, 7 :450, 1920. 

4. Dresel, Kurt : Spezielle Pathologie unt Therapie In- 

nere Krankeiten — 1924. Kraus and Brugsch., p. 211. 

5. Egger : Quoted by Dresel. 

6. Falcon-Lesses, Mark, and Proger, S. H. : Psychogenic 

fever. New Eng. Jour. Med., p. 1034, (Nov. 20), 1930. 

7. Jahn, F. : Beitr. z. Klinik d. Tuberculose, 70:429, 
1928. 

8. Kintner, A. R., and Rowntree, L. G. : Long continued 

low grade idiopathic fever. Jour. A. M. A., 102:889, 
(Mar. 24) 1934. 

9. Moro, E. : Habituelle hyperthermie. Monatschr. f. 

Kinderh., 14:214, 1916; Uber Rektale Hyperthermie im 
Kindersalter. Monatschr. f. Kinderh., 11:430, 1913. 

10. Reimann, H. A. : Habitual hyperthermia. Tour. A. M. 

A., 99:1861. (Nov. 26) 1932. 


FURTHER OBSERVATIONS ON THE DISTRIBUTION AND 
CONCENTRATION OF SULFANILAMIDE IN THE 
TISSUES OF THE BODY AFTER ENTERAL 
AND PARENTERAL ADMINISTRATION* 


JOHN J. ENGELFRIED, D.P.H. 

ANN ARBOR, MICHIGAN 


In a previous paper 1 results on the absorption, distribution and excretion of free sul- 
fanilamide in normal rabbits have been reported. A further study in the variation of 
the free and conjugated sulfanilamide content of various tissues and fluids of man and 
other animals showed very similar values. Very satisfactory results have been obtained 
with the method recommended by Marshall and his co-workers 2 for the quantitative de- 
termination of this drug. 

The rate of absorption of sulfanilamide into the blood varies with the individual ani- 
mal from day to day. 1 There is a marked 
variation in the ability of different animals 
to conjugate this drug, which can be easily 

*From the Department of Pediatrics and Infectious Dis- 
eases, University of Michigan. Read before the Michigan 
Academy of Science, March 18, 1938. 

February, 1939 


illustrated by the following example: Two 
adult female rabbits were injected intra- 
peritoneally with 150 milligrams of sulfan- 
ilamide per pound of body weight. Rabbit 


129 


SULFANILAMIDE— ENGELFRIED 


TABLE I. DISTRIBUTION OF SULFANILAMIDE IN THE TISSUES OF NORMAL RABBITS 


TISSUES, Et cetera 

. Rabbit 37* 

Rabbit 39* 

Free 

Sulfanilamide 

Conjugated 

Sulfanilamide 

Free 

Sulfanilamide 

Conjugated 

Sulfanilamide 

Blood 

7.7 mg. % 

15.2 mg. '% 

11.9 mg. % 

7.1 mg. % 

Heart 

5.9 

5.7 

6.4 

2.6 

Lung 

6.1 

1.5 

8.2 

4.7 

Liver 

1.4 

12.7 

1.6 

7.1 

Gall Bladder 

3.0 

12.4 

6.1 

6.6 

Spleen 

5.3 

5.9 

7.7 

3.8 

Kidney 

9.0 

7.6 

9.0 

5.1 

G. I. Muscle 

3.3 

3.7 

7.4 

0.5 

G. I. Contents 

3.5 

3.0 

9.5 

2.4 

C.N.S. 



4.9 

0 

Uterus 

i 


15.9 

6.0 

Muscle, Etc. 

4.4 

11.4 

6.0 

6.8 

Skin and Hair 

18.0 

6.7 

7.0 

2.3 

Body Fluid 

9.3 

10.2 

12.7 

3.3 

Urine 

89.9 

243.3 

121.2 

78.8 

Stool 



11.4 

4.2 


* Killed four hours after the intraperitoneal administration of 150 milligrams of sulfanilamide per pound of body weight. 


CHART I. SULFANILAMIDE ABSORPTION IN 
NORMAL RABBITS 

Mg. per 100 co. 



Solid Line — Total sulfanilamide. 

Dotted Line — Free sulfanilamide. 

38 was able to conjugate the drug quite 
rapidly arid the concentration in the blood 
of conjugated sulfanilamide was more than 
50 per cent of the total sulfanilamide ; while 
rabbit 39 was unable to conjugate it very 
rapidly. During the first four hours the 
conjugated sulfanilamide in the blood of this 


rabbit was not more than 10 per cent of the 
total (Chart 1). 

An analysis of the tissues** of eleven rab- 
bits showed a variation in their sulfanila- 
mide concentration (Table I). The concen- 
tration of free sulfanilamide is much lower 
in the liver than in the other tissues ; but the 
percentage of the conjugated drug in this or- 
gan is exceedingly high, indicating the pos- 
sibility of this organ playing a very impor- 
tant role in its conjugation. The percentage 
of sulfanilamide recovered from these two 
rabbits was 81.2 per cent (rabbit 37) and 
78.0 per cent (rabbit 39). The exact 
quantity administered was determined by 
subtracting the amount remaining in the 
syringe after injection and that remaining 
in the flask from the total determined 
amount. As a final precaution in account- 

**The rabbits and guinea pigs used in this study were 
anesthetized, and bled from the heart. The organs were 
removed, thoroughly washed in physiological saline solution 
and weighed. The larger organs and tissues were ground 
in a clean meat grinder, to insure a uniform mixture. 
Small portions of this ground tissue were extracted at room 
temperature with 96 per cent ethyl alcohol. All tissues 
were extracted three times, first for forty-eight hours and 
filtered through No. 42 Whatman’s filter paper; this resi- 
due being reextracted for twelve hours and filtered, and 
finally reextracted for three hours; the three filtrates be- 
ing combined and a portion analyzed. The smaller organs, 
those weighing less than ten grams, were cut into small 
pieces and extracted with the same technic. 

Jour. M.S.M.S. 


130 


SULFANILAMIDE— EXGELFRIED 


TABLE II. DISTRIBUTION OF SULFANILAMIDE IN THE TISSUES OF NORMAL 

GUINEA PIGS 



Guinea Pig 44* 

Guinea Pig 45* 

TISSUES, Et cetera 

Free 

Sulfanilamide 

Conjugated 

Sulfanilamide 

Free 

Sulfanilamide 

Conjugated 

Sulfanilamide 

Blood 

7.1 mg. % 

9.9 mg. % 

3.7 mg. % 

6.3 mg. % 

Heart 

5.2 

1.1 

1.6 

5.6 

Lungs 

2.8 

2.9 

1.0 

4.0 

Liver 

4.3 

3.8 

2.3 

3.1 

Spleen 

6.1 

8.1 

1.5 

5.5 

Kidney 

5.6 

8.3 

1.3 

3.2 

G. I. Muscle 

5.2 

5.6 

2.6 

4.0 

G. I. Contents 

12.9 

4.7 

6.1 

10.4 

C.N.S. 

3.6 

1.5 

1.7 

0.6 

Muscle, etc. 

5.3 

3.5 

2.0 

3.9 

Skin and Hair 

3.9 

4.5 

1.7 

3.0 

Urine 

102.6 

114.8 

74.5 

141.4 

Stool 



8.6 

4.0 

Embryo 


2.7 

4.3 


^Killed four hours after the intraperitoneal administration of 150 milligrams of sulfanilamide per pound of body weight. 


ing for the total sulfanilamide recovered, 
the washings from the instruments, the 
containers and the paper used beneath these 
containers were saved and analyzed for any 
possible sulfanilamide. 

The analysis of tissues of normal guinea 
pigs gave very similar results (Table II). 
However, the percentage of conjugated sul- 
fanilamide in the liver of the guinea pig is 
much less than in the rabbit. 

The percentage of sulfanilamide recov- 
ered from these two animals was greater 
than that recovered from the rabbits (88.5 
per cent and 96.4 per cent). The analysis 
of the tissues of one autopsied woman indi- 
cates that this drug is distributed in high 
concentrations through the various tissues 
of man (Table III). The total amount of 
sulfanilamide administered to this patient 
was not known; she had received some sui- 


table IV. EXCRETION OF SULFANILAMIDE IN NORMAL RABBITS 



Urine 

Stool 

Percentage of 
sulfanilamide 
in stool 


Total 

Sulfanilamide 

Free 

Sulfanilamide 

Total 

Sulfanilamide 

Free 

Sulfanilamide 

Rabbit 37 

354.7 mg. 

85.7 mg. 

3.4 mg. 

0.9 mg. 

0.9% 

Rabbit 38 

492.0 

94.0 

1.6 

0.0 

0.3% 

Rabbit 39 

681.9 

420.3 

0.16 

0.11 

0.1% 


TABLE III. DISTRIBUTION OF SULFANILAMIDE 
IN THE TISSUES OF MAN* 



Pt. 

O.B. 

Age : 21 

TISSUES, 
Et cetera 

Total 

Sulfanilamide 

V 

si 

“ rz 
X 

Conjugated 

Sulfanilamide 


mg. % 

mg. % 

mg. % 

Blood 

11.77 

8.88 

2.89 

Heart 

9.37, 

7.36 

2.01 

Lungs 

6.48 

5.40 

1.08 

Liver 

7.91 

5.02 

2.89 

Spleen 

9.56 

6.88 

2.68 

Pancreas 

6.29 

4.41 

1.88 

Kidney 

9.90 

5.29 

4.61 

Cerebrum 

4.48 

4.38 

0.10 


* Autopsy, fourteen hours after death. Diagnosis : Scar- 

let fever, streptococcus laryngo-tracheo-bronchitis, cervical 
abscess. 


February, 1939 


131 


SULFANILAMIDE— ENGELFRIED 


TABLE V. EXCRETION OF SULFANILAMIDE IN THE URINE OF MAN FIVE DAYS AFTER 
ADMINISTERING EIGHTY GRAMS OF THE DRUG DURING AN ELEVEN DAY PERIOD 


Time after 
drug 

discontinued 

Total 

Sulfanilamide 

Free 

Sulfanilamide 

Conjugated 

Sulfanilamide 

% Free 
Sulfanilamide 

0-12 

hours 





12-24 

hours 

740 mg. 

405 mg. 

335 mg. 

54.6% 

24-36 

hours 

814 

378 

436 

46.5 

36-48 

hours 

188 

74 

114 

39.7 - 

48-60 

hours 

248 

83 

165 

33.5 

60-72 

hours 

89 

24 

65 

27.5 

72-84 

hours 

57 

16 

41 

28.1 

84-96 

hours 

14 

5 

9 

35.8 

96-108 hours 

Trace 

0 

Trace 


108-120 hours 

Trace 

0 

Trace 



Patient — J. T., male, aged forty-five years. Diagnosis: 


fanilamide before entering the hospital. The 
concentration of the conjugated drug in 
the cerebrum was very low. 

Sulfanilamide is excreted in the urine. 
A very small percentage may be excreted 
in the evacuated stools* (Table IV). When 
the drug was administered intraperitoneal- 
ly and the animal had a stool within twenty- 
four hours after injection, the drug could 
be found in the specimen; however, if the 
animal was constipated and did not have a 
stool until sometime later the specimen was 
negative ; the drug may have been reab- 
sorbed from the lower intestinal tract. 

Traces of sulfanilamide have been found 
in the urine 120 hours after the last admin- 
istration of the drug (Table V). This pa- 
tient received eighty grams during an 
eleven-day period. The eleventh day his 
blood concentration was 9.2 mg./lOO c.c. ; 
twenty-four hours later it was 4.9 mg./lOO 


*To study the excretion of the drug, the animal was 

placed on a heavy wire frame suspended in a large jar. 

The stools were caught in a smaller mesh frame suspended 
beneath the larger frame, and fastened at a thirty degree 
angle to allow the stool specimens to roll down to a 
pocket in the lower frame, at the side of the jar ; the 

urine passed through the frames and was collected in the 
bottom of the jar. As a further precaution against chemi- 
cal contamination with the urine, the stool specimens 
were removed as soon as possible after evacuation and 
immediately washed several times in phvsiological saline 
to remove any possible trace of urine. The last washing 

was immediately tested for sulfanilamide to insure against 
the possibility of the stool being contaminated with urine 
and giving false positive results. The stool specimens 
were crushed and extracted with 96 per cent alcohol. 
Several pieces of the wire used in the construction of the 
frames were allowed to remain in a known concentration of 
chemically pure sulfanilamide for ten days, to determine if 
the wire used in the construction of these frames would 
cause any chemical change in the drug. 

132 


Erysipelas, with cellulitis. 


c.c,. and at the end of forty-eight hours, 
1.3 mg./lOO c.c. ; illustrating the gradual 
removal of the drug from the tissues. There 
was only a trace of sulfanilamide in the 
blood stream at the end of seventy-two 
hours. • 

Summary 

1. Free and conjugated sulfanilamide 
may be recovered from all organs, tissues 
and fluids of the rabbit, guinea pig and 
man. 

2. There is a very high percentage of 
conjugated sulfanilamide in the liver of nor- 
mal rabbits. 

3. The percentage of conjugated sulfan- 
ilamide found in blood and various tissues 
of these animals varies with the individual 
animal. 

4. Sulfanilamide is eliminated from the 
body in the urine as free and conjugated 
sulfanilamide. However, a small percent- 
age may be excreted in the stool. 

5. The complete elimination of the drug 
from the body will require several days, 
depending on the amount of drug stored in 
the tissue and the daily urinary output. 

6. The quantity of sulfanilamide recov- 
ered from the tissues and fluids of two nor- 
mal adult rabbits four hours after the intra- 
peritoneal injection of the drug was 78.0 
per cent and 81.2 per cent. 

7. Under the same conditions the per 
cent of recovery from two normal adult 


Tour. M.S.M.S. 


TREATMENT OF BURNS— SEEGER 


guinea pigs was 88.5 per cent and 96.4 per 
cent. 

Bibliography 

1. Engelfried, J. J. : Observations on the absorption, dis- 

tribution and excretion of sulfanilamide in normal rab- 


bits. Univ. Hosp. Bull., Univ. of Mich., 4:4-5, (Jan.) 
1938. 

2. Marshall, E. K., Jr., Emerson, K., Jr., and Cutting. 
W. C. : Paraaminobenzenesulfonamide ; absorption and 

excretion. Jour. A. M. A., 108:953-957, (Mar. 20), 
1937. 


THE TREATMENT OF BURNS* 

STANLEY J. SEEGER, M.D. 

MILWAUKEE, WISCONSIN 

It was in Detroit that the revival of interest in the treatment of burns 
had its inception. I welcome this opportunity to pay tribute to those men 
of your Association who were early workers in this field and whose 
labors have done so much for the alleviation of human suffering. 

In recent years there has been a more general recognition of the re- 
quirements for the proper care of burns. Linked with this changing 
attitude there is an increasing appreciation of the nature of the profound 
systemic changes which so often complicate these injuries. 

It is estimated that in 
thousand persons yearly lose their lives as 
a result of burns. Of this number 45 per 
cent are children under five years of age, 
and reliable statistics evidence the fact that 
these accidents kill nearly as many children 
under fifteen years of age as all other 
home accidents combined. Of the non- 
fatal home injuries, burns constitute a 
large percentage. The protracted suffering 
of the unfortunate victims of these trag- 
edies, the resulting disfigurement, and dis- 
ability and loss of morale present impor- 
tant economic as well as surgical and medi- 
cal considerations. Ignorance of the serious 
consequences of seemingly simple household 
accidents explains the carelessness which is 
the principal contributing factor in their 
cause. 'This fact offers physicians and 
nurses, in their daily contacts in homes, an 
opportunity to practice preventive medicine 
in a neglected field, and offers medical or- 
ganizations a worthwhile project to be in- 
cluded in their public health activities. 

Because they represent the commonest 
variety of burns, those produced by heat of 
a degree incompatible with proper function- 
ing of the tissues have been most intensive- 
ly studied. The symptoms following the 
infliction of a severe burn may be divided 
into three groups: the period of initial 


*Read before the Seventy-third Annual Meeting of the 
Michigan State Medical Society, Detroit, September 20, 
1938. 

February, 1939 


the United States alone, from six to seven 


shock; the period of secondary or so-called 
toxic burn shock; and the period of repair, 
which may or may not be complicated by 
infection. The cause of the constitutional 
symptoms immediately following burns has 
long been a matter of speculation and re- 
search, both clinical and laboratory. The 
term “shock” has been loosely applied in 
clinical medicine, and failure to define ac- 
curately conditions under discussion has 
given rise to confusion in the study of the 
clinical pathology" of burns. Primary shock 
is neurogenic in character, and is associated 
with vasodilatation and a decrease in blood 
pressure, and a consequent reduction in car- 
diac output. While this syndrome should 
always be looked for, it is usually found 
only in widespread burns effecting numerous 
nerve endings in the skin. It is concerning 
the so-called secondary toxic burn shock 
that much controversy exists. The con- 
troversy concerns both the mechanism of its 
production and the time factor involved. 
Two schools of thought predominate re- 
garding the fundamental character of this 
reaction. One maintains that at the site of 
the burn a toxic substance is elaborated by 
the action of heat on proteins. It is pre- 
sumed that the absorption of this toxin gives 
rise to the symptoms grouped under the 
term “toxic burn shock.” Other workers 
maintain that it is unnecessary to postulate 
the existence of a specific burn toxin, and 



S. J. Seeger 


133 



TREATMENT OF BURNS— SEEGER 


substitute the theory that the symptoms can 
be explained by the shifting of fluids in the 
body. 

In 1898 Bardeen reviewed the various 
theories on this subject. His conclusions, 
based on observed changes in the entire 
lymphatic systems of five children, who died 
several hours after being burned, were 
a substantiation of the theory that death 
at this stage is due to toxemia. Blalock 
and others have done important work 
which does not confirm the presence 
of a toxin such as earlier experimental 
results seemed to prove. Wilson has 
come to the conclusion that evidence for 
a specific burn toxin is inconclusive although 
much of it is suggestive. He maintains 
that proof of the toxin theory requires the 
demonstration and identification of the toxic 
substances not only in the burned area, but 
also in the circulating blood. Working with 
others he demonstrated in experimental ani- 
mals the development of toxicity in the 
edema fluid which accumulates in a burned 
area, this property being gradually acquired 
over a period of 48 hours. Controversy 
exists as to the possibility of absorption of 
toxic material from a burned area. Wilson 
concluded that the toxicity of edema fluid 
was independent of the growth of organ- 
isms in the burned area. Underhill main- 
tains that following a burn the permeability 
of the capillaries is in one direction only, 
namely, from the capillaries to the tissues. 
Recently Mason has demonstrated the ab- 
sorption of potassium iodide from burned 
areas, the excretion of this substance being 
the same as in normal animals. 

The confusion regarding the use of the 
term “toxic burn shock” is exemplified by 
the existing opinions concerning the time 
of onset of this syndrome. One author 
states that it occurs one hour after the in- 
fliction of a severe burn; another, that it 
may occur from six to fifty hours after- 
ward, and a third states that all shock seen 
during the first 24 hours is primary in char- 
acter. Harkins’ experimental demonstration 
that in a burned extremity half of the fluid 
lost from the blood vessels to the tissues is 
lost within the first hour is of importance in 
considering the time of onset of secondary 
shock. This loss may be as much as 2 
per cent of the body weight. The blood 
pressure is not as satisfactory a prognostic 
sign as is the hemoglobin percentage or 

134 


hematocrit reading. Some evidence has 
been advanced which tends to show that in- 
fection plays a role in the production of this 
early toxemia. Infection is probably not an 
important factor earlier than the second dav 
in many cases. In a recent case, with exten- 
sive second degree burns, and marked tox- 
emia on the third day, dramatic improve- 
ment was observed by us following the use 
of sulfanilamide. The early theories which 
attributed the reaction to burns as due to 
interference with the functioning of the 
skin have been generally discarded, although 
it is becoming apparent that our knowledge 
of the physiology of the skin is far from 
complete. 

A burn is defined as an injury to tissues 
produced by a degree of heat incompatible 
with their proper functioning. These in- 
juries are classified on various bases. Many 
authors have written on the general treat- 
ment of burns in the past few years. There 
seems to be rather widespread agreement 
that there is a succession of stages or pe- 
riods in burns but the terms to designate 
them vary widely. The difference in 
terms is in most instances a difference in 
opinion as to the etiology of the various 
stages. None of the suggested classifica- 
tions is superior to that which has been used 
in the past. In considering the cause of 
the trauma of burns the most commonly rec- 
ognized grouping is into scalds produced 
by moist heat, and burns due to dry heat, 
x-ray and radium burns, electrical burns, 
sun burns or erythema solare, and chemical 
burns. In addition, burns are classified on 
the basis of the depth of tissue injury and 
the extent of skin surface involved. In this 
country and in Germany the so-called Amer- 
ican classification is most generally used to 
indicate depth of tissue involvement. It 
recognizes three degrees of burning: first 
degree, characterized by erythema or hyper- 
emia; second degree, associated with ves- 
icle formation; and third degree, in which 
there is destruction of tissue with eschar 
formation. In some classifications a fourth 
degree is added, this being applied to the 
charring of tissue. Bancroft and Rogers 
recently suggested that the present third de- 
gree burns be divided into those which do 
not destroy the hair follicles and those 
which do, and Goldblatt has proposed divid- 
ing burns into scar- forming and nonscar- 
forming varieties. In attempting to apply 

Jour. M.S.M.S. 


TREATMENT OF BURNS— SEEGER 


these latter classifications, as is also true of 
the classification of Dupuytren, into six de- 
grees, one encounters the difficulty of judg- 
ing the depth of tissue involvement. The 
depth of burns is often underestimated, even 
by clinicians of wide experience, and the 
American classification, while leaving some 
things to be desired, is probably as satisfac- 
tory as can be devised. Not infrequently 
one is asked to see a patient who has been 
told that a burn from which he is suffering 
is mild, when it is actually a third degree 
burn and convalescence is prolonged much 
beyond the anticipated time. The various 
degrees of burns are frequently associated, 
and it is a common mistake, in severe exten- 
sive burns, to overlook first degree burning 
about the margins of the more serious 
lesions. 

While it has long been recognized that 
the extent of burns is of relatively greater 
importance than the degree, no practical 
means of estimating the extensiveness of 
these lesions was available until Berkow 
perfected a method in 1924. This method 
provides an accurate, simple means of de- 
termining the proportion of body surface 
involved and should be utilized in conjunc- 
tion with the pathologic classification. 

In treating burns one should proceed on 
a carefully studied plan. The mistake 
should not be made of overlooking the 
symptoms of shock in the enthusiasm of 
treating the local wound. The most im- 
portant indications where shock exists are 
to relieve pain by adequate doses of mor- 
phine or codeine, which latter is preferable 
for children, to apply external heat and to 
administer fluids by mouth, by rectum or 
intravenously. Blood transfusion is a most 
efficacious procedure. Because of the con- 
centration of the blood there are arguments 
in favor of giving blood serum alone rather 
than whole blood. The blood chlorides are 
usually low in severe burns and their re- 
placement by the administration of sodium 
chloride solution intravenously should re- 
ceive careful consideration. As soon as the 
patient’s general condition permits, attention 
should be given the wound. Penberthy has 
emphasized the importance of the treatment 
of these wounds with the same care as one 
treats other surgical wounds and has out- 
lined a very satisfactory routine technic. 
Pain should be relieved by morphine, co- 
deine or avertin. The patient should be 

February, 1939 


kept warm. Debridement should be super- 
ficial and confined only to tissue which is 
obviously loose and destroyed, and foreign 
matter which may be present on the wound 
should be removed. Gentle cleansing of the 
area with soap and water is an efficacious 
method. When patients are first seen after 
emergency treatment elsewhere, greasy 
dressings may be removed with xylene, 
ether, benzine or isopropyl alcohol. 

In 1925 Davidson suggested the possibil- 
ity of limiting the absorption of toxic mate- 
rial from burned surfaces by coagulation 
or precipitation of injured proteins. His 
studies of the efficiency of various agents 
led to the development of the tannic acid 
method of treating the local wound. Be- 
cause tannic acid possesses the property of 
precipitating protein, Davidson assumed that 
through its use, fixation of the burned tis- 
sues could be accomplished and the absorp- 
tion of toxic material prevented. The effect 
of tannic acid is to produce a firm, smooth 
mahogany colored membrane which acts as 
a protective coating against chemical, bac- 
terial, and mechanical action, as well as 
against sensory irritation from other 
sources. One striking effect of the use of 
tannic acid is the relief of pain, which oc- 
curs promptly and often makes further use 
of sedatives unnecessary. McClure recently 
demonstrated that evaporation from the 
burned surface has a negligible effect in pro- 
ducing dehydration after a burn. For this 
reason the early arguments advanced for the 
use of tannic acid, on the basis that it pre- 
vents water loss from the surface, cannot be 
given much weight. 

The method of procedure as outlined bv 
Davidson is to cover the burned area with 
dry sterile gauze packs which are held in 
place by sterile gauze bandages and this 
dressing is then soaked by an aqueous solu- 
tion of tannic acid. In his early work 
Davidson used a 2.5 per cent aqueous solu- 
tion of tannic acid and at times used solu- 
tions as concentrated as 5 per cent. At the 
end of about 24 hours the dressing is re- 
moved, at which time tanning should have 
occurred. Secondary infection, especially in 
superficial burns, is limited because of lack 
of favorable material for the growth of or- 
ganisms. The protective area of coagulated 
protein may act as a scaffold for the growth 
of epithelium. One of the important func- 
tions of the skin is the mechanical protec- 


135 


TREATMENT OF BURNS— SEEGER 


tion it affords by cloaking the body in a 
complete mantle of dead material, thus keep- 
ing the organism, to some extent, isolated 
from its environment. The formation of a 
crust or scab by tannic acid temporarily re- 
stores to the body some of the biological 
functions of the skin destroyed, thus allow- 
ing the organism to readjust itself to altered 
physiological conditions during a period 
when the patient is often struggling with 
shock. 

Since Davidson first described the technic, 
various modifications have been suggested, 
one of the most valuable being that the solu- 
tion be sprayed over the burned area. For 
this purpose an atomizer or ordinary spray- 
ing apparatus is effective, the entire area 
being sprayed every fifteen minutes until a 
membrane of the desired consistency is pro- 
duced. This is usually accomplished within 
from twelve to fifteen hours. Following the 
thorough tanning of the wound, the burned 
area may be kept uncovered if the patient 
is being treated under a light cradle, or cov- 
ered with clean sheets or towels. No dress- 
ing is necessary to protect the wound from 
contamination as this is effectively accom- 
plished by the impervious membrane. The 
margins of the wound should be carefully 
inspected several times daily and blebs 
which may appear should be opened and the 
areas painted with a mild antiseptic. In 
addition, the crust should be dried at inter- 
vals of about four hours with a warm air 
blower, the ordinary hair drying device be- 
ing satisfactory for this purpose. If the 
burn is of second degree or of moderately 
severe third degree, healing will take place 
underneath the crust and no further dress- 
ing is necessary, the crust curling at the 
edges and separating from the underlying 
tissues as healing takes place. 

When the burn is deep and extensive, 
epithelization will not take place and infec- 
tion of varying degrees of severity is not 
unusual. If by the fifth day the fever does 
not show evidences of subsiding or if a pa- 
tient who has previously had a low fever 
begins to develop evidences of infection, the 
crust should be carefully investigated. Areas 
which are tender or which are elevated and 
feel boggy should be incised, and if infec- 
tion is found underneath the crust, the loose 
portions should be removed and treatment 
with wet dressings instituted. The removal 
of the tanned membrane is facilitated by the 


application of large wet dressings of 10 per 
cent soda bicarbonate solution. As a rule 
it is not necessary to anesthetize these pa- 
tients or to remove large areas of membrane 
at one sitting, as the piecemeal removal can 
be accomplished within a few days. If no 
evidence of infection occurs, but the tanned 
membrane does not separate, one should not 
allow the membrane to be undisturbed for a 
period of longer than ten days or two weeks. 
At the end of this time, should the mem- 
brane still be firmly attached to the wound, 
it should be investigated by incising through 
it. One may find granulation tissue under- 
neath the crust and epithelization will be 
delayed unless the crust is removed and 
more active treatment instituted. 

Several modifications of the tannic acid 
treatment have been proposed. The tanning 
process is a complicated one, and the im- 
portance of using solutions of a normal 
hydrogen-ion concentration has been well 
demonstrated. The acid solutions usually 
used produce a very rapid fixation of tannin 
on the surface and have a tendency to aug- 
ment the edema of the underlying tissues. 
The following is a formula for making a 
solution of tannic acid (U.S.P. ) of normal 
pH: Dissolve 3.975 gm. pure anhydrous 

sodium carbonate and 25 gm. tannic acid in 
water and dilute to 500 c.c. Solutions of 
tannic acid should always be freshly made 
up, and this can be done easily by keeping 
on hand weighed out quantities of tannic 
acid and of sodium carbonate in separate, 
tightly stoppered bottles. 

The fact that the mortality rate in the 
early stages may be lowered means that 
more patients will reach the stage of the 
large granulating wound. The treatment 
of these wounds offers a challenge which is 
worthy of any surgeon. These patients 
present the problems of maintenance of 
body nutrition, the control of infection, the 
preparation of the granulating surface for 
the reception of skin grafts, the grafting 
of skin, and the prevention of contractures 
and ankylosis. Mastery of the technics in- 
volved in the accomplishment of these vari- 
ous objectives is far from being universal. 
The application of pressure dressings for 
the control of exuberant granulations is an 
old method which has assumed, only within 
recent years, a place consistent with its 
value. A well established principle in the 
treatment of large granulating wounds is 

Jour. M.S.M.S. 


136 


TREATMENT OF BURNS— SEEGER 


that an attempt should be made to cover 
them with epithelium at the earliest possible 
moment. The derma, or true skin, is de- 
rived from the mesoderm and is, therefore, 
a tissue which is not designed to serve as 
a source of epithelial development. While 
small areas of the stratum germinativum of 
the epidermis may remain viable in exten- 
sive burns, and at times undestroyed hair 
follicles may act as centers for the growth 
of epithelium, one should not delay too long 
in the hope that epithelization will be 
brought about in this manner. Ingrowth 
from the margins of the wound is to be re- 
lied on only in bums of small areas. De- 
lay in epithelization means an increase in 
scar tissue and greater deformity. 

The importance of attention to the de- 
tails of nursing technic, looking to the com- 
fort and well-being of the patient, cannot be 
over-emphasized. Encouragement of active 
motion, massage over unaffected areas, at- 
tention to the functions of the unburned 
skin, diversion to improve the morale, and 
extreme patience and avoidance of pain in 
movement or dressings are among the most 
important considerations. During the con- 
valescence stage, blood transfusion is fre- 
quently a valuable adjunct. The importance 
of proper dietetic regulations should con- 
stantly be kept in mind. We are only be- 
ginning to learn the importance of various 
vitamins in diseased conditions. At the 
Milwaukee Children’s Hospital we have be- 
gun the study of the vitamin C content of 
the blood in burned patients. Methods for 
the determination of the concentration of 
other vitamins which may have a part in 
the growth of epithelium and of supporting 
structures have not been developed but they 
offer a field for research and will undoubt- 
edly prove to be of great clinical value in 
the future. 

The following statement is interesting in 
connection with the subject of a reduction 
in mortality following various methods of 
treatment: “The local treatment of burns 
is a subject on which many books have been 
written and perhaps more numerous reme- 
dies recommended than in any branch of 
surgery. The success which is said to have 
attended very different, and even opposite, 
modes of treatment, shows that the authors 
must either be misrepresenting the facts or 
speaking about different matters. I prefer 
the latter explanation, more especially as I 

February, 1939 


find authors who have written to recom- 
mend certain methods have almost invari- 
ably spoken of burns as if they were all 
alike, forgetful, apparently, that the essen- 
tial question in the treatment of a burn is 
the depth or the degree, the consequent 
probability of sloughing, ulceration, or mere 
inflammation resembling erysipelas. It is 
only by keeping this point steadily in A'iew 
that we can hope to arrive at any rational 
plan for the treatment of these injuries.” 
This statement, which is so true today, was 
written fifty years ago by Holmes in his 
System of Surgery and was recently quoted 
by Dunbar in “A Review of the Burn Cases 
Treated in the Glasgow Royal Infirmary 
During the Past Hundred Years.” 

Regardless of its ultimate place in the 
therapy of burns, Davidson’s contribution 
served to stimulate a revival of interest in 
this subject. At the present time it is not 
possible to demonstrate by the statistical 
method the effect which the tannic acid 
method of treatment has had upon mortal- 
ity. It is probable that a more general ap- 
preciation of the nature of the systemic 
changes has had as much to do with any 
apparent decrease in the death rate as has 
any single method of treating the local 
wound. The treatment of local lesions dif- 
fers greatly. Willems and Kuhn report 47 
different methods used in the treatment of 
752 burns on the records of an insurance 
company. The routine use of blood trans- 
fusion and the addition of fluids and chlo- 
rides to the depleted vascular supply have 
been important factors in reducing the mor- 
tality rate during the first few days. In 
some reported series more patients survive 
than formerly the periods of initial and 
secondary shock, only to die at a later stage 
of exhaustion, sepsis, or pneumonia. 

Bibliography 

Bancroft, F. W., and Rogers, C. S. : Treatment of cuta- 

neous burns. Ann. Surg., 84:1, 1926. 

Bardeen, Charles R. : A review of pathology of superficial 

burns, with a contribution to our knowledge of patho- 
logical changes in the organs in cases of rapidly fatal 
burns. Johns Hopkins Hosp. Rep., 7 : 1 3 7, 1898. 
Berkow, Samuel : Method of estimating extensiveness of 

lesions (burns and scalds) based on surface area pro- 
portions. Arch. Surg., 8:138, 1924. 

Bettman, A. G. : Burns; treatment of shock and toxemia; 

healing the wound; reconstruction. Am. Jour. Surg., 
20:33, 1933. 

Blair, V. P., and Brown, J. B.: Use and uses of large 

split-skin grafts of intermediate thickness. Tr. South. 
S. A., 41:409, 1928; also, Surg., Gynec. and Obst., 
49:82, 1929. 

Blair, V. P., and Hamm, W. G. : Early care of burns and 

repair of their defects. Jour. A.M.A., 98:1355, 1932. 
Blalock, A.: Experimental shock: VII. Importance of 

local loss of fluid in production of low blood pressure 
after burns. Arch. Surg., 22:610, 1931. 

Brooks, B., and Blalock, A. : Shock with particular refer- 

137 


TREATMENT OF BURNS— SEEGER 


ence to that due to hemorrhage and trauma to muscles. 
Ann. Surg., 100:728, 1934. 

Brown, J. B., and Blair, V. P. : Repair of defects result- 
ing from full thickness loss of skin from burns. Surg., 
Gynec. and Obst., 60 :379, 1925. 

Davidson, E. D. : Tannic acid in treatment of burns. 

Surg., Gynec., Obst., 41 :202, 1925. 

Ibid: Prevention of toxemia of burns; treatment by tannic 

acid solution. Am. Jour. Surg., 40:114, 1926. 

Ibid : Sodium chloride metabolism in cutaneous burns and 

its possible significance for rational therapy. Arch. 
Surg., 13:262, 1926. 

Ibid: Treatment of acid and alkali burns. Ann. Surg., 

85:481, 1927. 

Dunbar, John: Review of the Burn Cases Treated in the 

Glasgow Royal Infirmary During the Past Hundred 
Years (1833-1933) with Some Observations on the 
Present Day Treatment. Glasgow Med. Jour., 122 :239, 
1934. 

Goldblatt, Davis : Contributions to the study of burns, 

their classification and treatment. Ann. Surg., 85 :490, 
1927. 


Harkins, Henry N. : Recent advances in the study of burns. 

Surg., 3:430, 1938. 

Mason, J. B. : Evaluation of tannic acid treatment of 

burns. Ann. Surg., 97 :641, 1933. 

Penberthy, G. C., and Weller, C. N. : Complications asso- 

ciated with treatment of burns. Am. Jour. Surg., 26 : 
124, 1934. 

Seeger, S. J. : Treatment of burns: with report of 278 

cases. Wis. Med. Jour., 31 :755, 1932. 

Ibid: Hydrogen-ion concentration value of tannic acid 

solutions used in treatment of burns. Surg., Gynec. 
and Obst., 55:455, 1932. 

Ibid: The Treatment of Burns. Dean Lewis Practice of 

Surgery, Vol. 1, Chap. 17. Hagerstown, Md. : Wm. 
F. Prior Co., Inc. 

Underhill, F. P. : Significance of anhydremia in extensive 

superficial bums. Jour. A.M.A., 95 :862, 1930. 

Willems, J. D., and Kuhn, L. P. : Burns: A statistical 

study of 1,206 cases. Am. Jour. Surg., 34:254, 1936. 

Wilson, W. C., et al. : Toxin formation in burned tissues. 

Brit. Jour. Surg., 24:601, 1937. 


BACTERIA TRAVEL BY AIR 

Moist dust particles are the airships of bacteria. When bacteria alone are present in the 
air, they quickly dry out and die. The lucky ones are those coughed, sneezed or otherwise 
sprayed onto moist dust particles, upon which these bacteria ride and live so long as mois- 
ture may be present. 

When bacteria were first discovered, the public was much concerned lest these new 
enemies fly through the air and attack like gnats or mosquitoes. Slowly this concern gave 
way to the belief that germs are chiefly distributed by direct contact between normal persons 
and persons or substances harboring the microbes. Now, fifty years later, it appears proved 
that some harmful bacteria may ride around in the air and that infection may be inaugu- 
rated by breathing this air. 

This new development has caused a study of the bacteria in the air of work places in 
Detroit. Dr. Carey P. McCord, Director of the Bureau of Industrial Hygiene of the 
Michigan Department of Health, who supervised this investigation, states : “This study has 
been made to determine the numbers and types of bacteria that may be present in indus- 
trial work places. The results show that the air of workrooms with regard to numbers 
and kinds of germs present, are no worse than schools, offices and hospital wards.'’ Dr. 
McCord claims that the real danger of acquiring bacterial diseases in work places still is 
through direct contact. “Our investigation proves that the average industrial worker does 
not spend a work day of seven or eight hours in a heavily germ laden atmosphere.” 

The number of bacteria riding in the air on dust particles depends primarily upon the 
extent of the worker congestion in the work place, upon the effectiveness of general venti- 
lation, the humidity and temperature of the air, together with the amount of activity going 
on in the workroom. Dr. McCord states that “Overcrowding of workers in factories direct- 
ly invites the spread of respiratory diseases and in order to prevent overcrowding every 
worker should be provided at least 25 square feet of floor space.” 

All bacteria gaily sailing around on their dusty airships should be grounded. A small 
number of bacteria in the air are comparatively unimportant in a workroom, but when 
scores of workers in congested areas launch, by coughing and sneezing, millions of bacteria 
into the air — then look out for the coming epidemic. 


138 


Jour. M.S.M.S. 


STAFF CONFERENCE 
DEPARTMENT OF INTERNAL MEDICINE 
UNIVERSITY OF MICHIGAN 


Case History 

A. H., a white farmer boy, aged sixteen, was re- 
admitted to the University Hospital on October 10, 
1938, because of an upper respiratory infection and 
drowsiness. He was first seen here on October 18, 
1934, because of ease of fatigue, a large appetite, 
polyuria and polydipsia, at which time it was found 
that he had diabetes mellitus. His diabetes was 
well controlled by means of dietary regulation and 
the administration of insulin three times daily. 


acetone odor to the breath. There was injection of 
the nasal mucous membranes and throat. The thy- 
roid was easily palpable with slight symmetrical en- 
largement. The lung fields were clear and the heart 
w T as not abnormal. His abdomen was distended and 
tenderness was generalized, but there were no palpa- 
ble visceral enlargements. The remainder of the 
examination was not abnormal. 

Laboratory Findings . — The urine on admission 
showed : specific graviey 1.022, albumin — f-, sugar 


Treatment in Hospital: 


10-10-38 

Urine 

Insulin 

Blood 

Blood 

Remarks 


Sugar 

Acetone 

(regular) 

n 

O 

Sugar 

Gastric lavage with 4% sodium bicar- 







bonate. 

1:00 P.M. 

4+ 

4+ 

40 U 

13 vol. 

422 Mg. 

100 c.c. of orange juice left in stomach. 





% 

% 

Intravenous saline (physiologic) started. 

3:15 P.M. 

4+ 

4+ 

40 U 



I.V. 1/6 molar-sodium lactate started. 

5:30 P.M. 

4+ 

4+ 

30 U 



200 c.c. orange juice 

8:00 P.M. 

4+ 

4+ 

20 U 



200 c.c. orange juice 

9:00 P.M. 

4+ 

4+ 





10:00 P.M. 

4+ 

2+ 

20 U 



200 c.c. orange juice 

12:00 P.M. 

3+ 

2+ 

20 U 



200 c.c. orange juice 

10-11-38 







2:00 A.M. 

4+ 

2+ 

20 U 



200 c.c. orange juice 

4:00 A.M. 

3+ 

2+ 

20 U 



200 c.c. orange juice 

6:00 A.M. 

3+ 

1+ 





8:00 A.M. 

1 + 

1 + 

20 U 

54 vol. 

133 Mg. 

200 c.c. orange juice 





% 

% 

plus 20 gm. glucose. 


His course was entirely satisfactory after dis- 
charge. The carbohydrate content of his diet and 
the insulin dosage were increased when he was seen 
on subsequent visits. In August, 1937, his diet was 
increased to 200 gm. A.G. (available glucose) and a 
single morning dose of protamine insulin was substi- 
tuted for the regular insulin. Minor changes were 
made and when last seen in the Diabetic Clinic in 
September, 1938, he was receiving a diet of 300 gm. 
A.G., 3,600 calories and a single dose of protamine 
insulin 86 units (of U 80) each morning at 7 :30. 
He was considered to be well regulated at this time. 

Ten days prior to his return he developed a head 
cold, a cough, headache, malaise, drowsiness, and a 
stiff neck. There was a return of the polyuria and 
polydipsia ; his diet was discontinued on the evening 
of October 9, 1938, and his last dose of insulin, 86 
units of protamine, was given at 7 :30 A.M. on Oc- 
tober 9. He developed abdominal pain and was 
brought to the hospital shortly after noon on Oc- 
tober 10, 1938. 

The patient’s brother died at 14 years of diabetes 
mellitus. There was no other familial history of the 
disease nor other factors of significance. His past 
history was non-contributory except as noted above. 

Physical Examination . — On admission his temper- 
ature was 97.3° F., pulse 117 per minute, respira- 
tions 24 per minute, and the blood pressure 145/75. 
Examination revealed a semi-stuporous boy who 
exhibited typical Kussmaul breathing, a flushed 
face, warm dry skin, cherry red lips, and a strong 

February, 1939 


+ 4H — h with 6-10 coarse granular casts per low 
power field, but no red or white blood cells. The 
plasma carbon dioxide combining power was 13 vol- 
umes per cent and the blood sugar 422 mg. per 100 
c.c. at 1 :00 P. M., October 10. Blood Studies : 
R.B.C. 4,650,000; Hb. 97 per cent (Sahli), W.B.C. 
9,150, and there was an essentially normal differen- 
tial count. 

Totals: Two hundred thirty units of regular in- 
sulin were given subcutaneously. 1,500 c.c. of phys- 
iological saline and 1,920 c.c. of 1/6 molar sodium 
lactate were injected intravenously, by the drip 
method, over a period of four hours. His improve- 
ment was rapid and his subsequent course was un- 
eventful. He was placed on a diet of 250 gm. of 
carbohydrate, 100 gm. protein, and 3,600 calories and 
controlled on regular insulin. 

Discussion 

Dr. Julian Tobias: In addition to the history 

noted above, I would like to point out that during 
his course of treatment his blood pressure rose from 
146/75 to 200/90. The next day, however, it had 
returned to the admission level. 

Dr. Cyrus C. Sturgis : Dr. Newburgh, will you 
discuss this case? 

Dr. Louis H. Newburgh : The patient presents 
two or three factors that are characteristic of dia- 


139 


STAFF CONFERENCE 


betic coma. The abdominal pain, for instance, has 
frequently been mistaken for some condition that 
required immediate surgical intervention. I believe 
that now most surgeons realize the situation, but 
over and over again patients have been rushed to a 
hospital because of a serious generalized disturbance 
localized in the abdomen, and have undergone an 
operation which, of course, makes the situation 
very much more difficult to manage. The abnormali- 
ties in the urine — albumin and casts — are character- 
istic. These have been known to occur for a very 
long time. Years ago a great deal of fuss was 
made about that. They are evidently due to a mild 
toxic effect on the renal epithelium. Sometimes this 
is very great. Certainly patients who have a mod- 
erate acidosis for a long time — that is, a degree of 
acidosis which does not cause coma but which is 
sufficient to incapacitate them — may develop severe 
renal injury. Renal damage may indicate, in this 
sense, a kidney which is so seriously disturbed as to 
cause retention of all the excretory substances, in- 
cluding the metabolic products such as the sulphates 
and phosphates, as well as the ketone bodies. These 
in turn tie up base so that when the patient comes 
in to the hospital in coma, there is often not only an 
organic but also an inorganic acidosis. Depletion of 
base is not merely due to retention of these factors 
but it is also caused by the prolonged excretion of 
the ketone bodies ; the patient develops a very 
low C0 2 combining power, Kussmaul breathing 
and unconsciousness. Complete relief of the organic 
acidosis may be accomplished, as is evidenced by the 
absence of ketone bodies in the urine, but the pa- 
tient may continue to remain in coma. He still has 
all the symptoms of acidosis, and it is important to 
realize that he is now suffering from an inorganic 
acidosis, which is the result of severe depletion of 
base. If recognized, this can be corrected almost 
immediately by the administration of sodium bicar- 
bonate. But if overlooked, a fatal outcome is almost 
certain. This is not very common, and not true in 
this patient. Undoubtedly some of the fatalities oc- 
curring in diabetic acidosis are attributable to this 
condition. 

There is a patient now on Dr. Smith’s ward who 
is perfectly familiar with diabetic acidosis, since she 
has had many bouts of it. She was admitted this 
time with a typical episode, which was perhaps 
somewhat more severe than usual. The striking 
feature is that she has a fever of 105° F. and has 
a leukocytosis of 21,000 cells per cubic millimeter. 
Her CO 2 combining power is 22 vol. per cent. She 
is recovering, and we are doing nothing about the 
fever and leukocytosis, even though she has abdom- 
inal pain, which practically every patient with severe 
acidosis experiences. It is especially interesting to 
realize that she has this very high fever, very marked 
leukocytosis as features of acidosis. She is quite 
sure that she has had this sort of response over and 
over again. There is nothing unusual about this as 
patients often have fever with acidosis. I can’t ex- 
plain the fever or the leukocytosis. 


Dr. Sturgis : Dr. Conn, do you have anything to 
add? 

Dr. Jerome Conn : I might add one or two points 
with regard to therapy. I would like to outline 
briefly what should be done for a patient who is ad- 
mitted to the ward in diabetic coma. One should 
realize that there are two essential abnormalities 
from which the patient is suffering. The first is 
lack of oxidation of glucose. This can be taken 
care of by means of insulin. The second is dehydra- 
tion, which is treated by giving fluids intravenously, 
either as 5 per cent glucose or as physiological sa- 
line. The intravenous infusion should be started 
immediately on admission. Insulin should be given 
as soon as one is positive that the patient is suffer- 
ing from diabetic coma. The initial dose of insulin 
should be 30 to 40 units. Larger doses are not nec- 
essary. Intravenous insulin is not necessary. Con- 
tinue with small doses, after the initial one, that is, 
20 units every two to three hours, obtaining urine 
specimens before each succeeding dose of insulin. 
Thus one can tell when to begin diminishing the 
dose of insulin. Catheterize for urine specimens if 
necessary. 

These two procedures, combating dehydration and 
organic acidosis by means of insulin and fluids, will 
take care of 90 per cent of the patients in diabetic 
coma. 

The other 10 per cent are suffering from deple- 
tion of base and should, in addition to the usual 
treatment, be treated with sodium bicarbonate or 
sodium lactate. It does not matter which is used 
as long as the condition is recognized as depletion 
of base. This is an important point because there 
are many schools in this country that feel that so- 
dium therapy is not indicated. We feel that in this 
10 per cent it is of utmost importance, and may be 
life-saving to the patient. 

Some may wonder why this patient was given 
glucose by mouth in the form of orange juice. 
About a year ago I had an idea that it might be of 
value to give glucose by mouth. The reason for 
such an assumption is this. Patients in diabetic 
coma are suffering from severe depletion of their 
glycogen stores. It seems that when the glycogen 
stores of the liver are replaced by means of insulin 
and carbohydrate, oxidation proceeds rapidly. In- 
sulin alone is often unsuccessful in promoting rapid 
oxidation when the liver glycogen is low. If the liv- 
er glycogen can be raised rapidly, we should expect 
a more rapid recovery. When glucose is absorbed 
from the gastrointestinal tract, it reaches the liver 
in a high concentration by means of the portal vein 
and the glycogen stores of the liver are replaced 
much more rapidly than when glucose is given in- 
travenously and arrives at the liver via the hepatic 
and mesenteric arteries. 

We had an opportunity to study three cases of 
diabetic coma whose treatment consisted of the 
usual regime to which was added 150 to 200 gram« 
of glucose by stomach tube. We were surprised to 
find in these cases that the C0 2 combining power 

Jour. M.S.M.S. 


140 


STAFF CONFERENCE 


rose from the region of 10 to 15 volumes per cent 
to 50 volumes per cent within a four hour period. 
This is a much more rapid recovery than we usually 
observe with the routine treatment. For this reason 
we wish to continue to study this observation. 

Dr. Sturgis : It is difficult for the younger men 
to appreciate, to the fullest extent, what the recov- 
ery of this patient means. Now it is expected that 
a patient with impending coma or coma will recover 
within a relatively short time after treatment has 
been instituted. Before 1922, i.e., before the use of 
insulin, when a patient went into diabetic coma he 
almost invariably died, though this did not include 
those in impending coma. 

Dr. Raphael Isaacs : In connection with the 

possible causes of leukocytosis in diabetes, Gottsegen 
and Wittman noted that the injection of ketone 
bodies, such as beta hydroxybutyric acid, into ani- 
mals caused a marked and definite leukocytosis. 
This may be a suggestion as to the cause of leuko- 
cytosis in diabetic patients in whom the ketone 
bodies are present in appreciable amounts. 

Dr. Herman Riecker: I do not understand why 
this patient had an albuminuria and hypertension. Is 
this frequently observed? How man}? cases of dia- 
betic coma show a hypertension. 

Dr. Newburgh : Renal damage is responsible for 
the albuminuria. I do not know what caused the 
hypertension. One more point. The patient has been 
receiving 86 units of protamine insulin in a single 
dose. One must realize, of course, that this form 
of insulin acts at the same rate throughout the 24 
hours. During the 8 to 10 hours of the day when 
all the food is taken, glycosuria may be seen. To- 
ward the end of the 24 hours, if no food is added 
and with the system continuously active, hypogly- 
cemia may be seen. If glycosuria is to be avoided 
during that early part of the day, a too low blood 
sugar will result at the other end, that is, during the 
last of the 24 hour period. 

A single dose of protamine insulin to avoid hypo- 
glycemia in the early morning and at the same time 
prevent glycosuria throughout the day is our ob- 
jective. It is questionable whether it is good or bad 
practice to give patients with severe diabetes a single 
large dose of protamine insulin in the morning, and 
to provide enough carbohydrate during the day to 
supply a sufficient amount in the early morning so 
that there will not be hypoglycemia ; but as an in- 
evitable part of such a practice, there will be gly- 
cosuria during the 8 to 10 hours of the day when 
food is given. Is glycosuria of that type harmful 
or net? That is a question for which I have no 
answer. 

Dr. Henry Field, Jr. : I expressed myself fifteen 
years ago, and I still feel the same way — in favor 
of using sodium bicarbonate in severe acidosis at the 
beginning of treatment rather than waiting for the 
indication of inorganic acidosis. I have a fear of 
waiting because I have seen a number of fatalities 


from uncomplicated diabetic acidosis in patients 
whose blood C0 2 had been restored to normal. I 
believe the point is that it had not been restored 
soon enough. It takes a certain amount of time for 
insulin to cause enough metabolism of ketones to 
improve the acidosis significantly. A severe acidosis 
is damaging to tissues. If continued long enough 
there is a time at which the injury becomes irrep- 
arable. Unless the acidosis is promptly relieved by 
alkalies to the point where it is no longer damag- 
ing, injury may be caused before insulin has had 
time to relieve the acidosis sufficiently. I favor the 
intravenous route of administering alkalies because 
in diabetic acidosis there is no certainty that any- 
thing given by mouth will pass the pylorus. It may 
all be vomited after a few hours. Intravenous ad- 
ministration of sodium bicarbonate is safe if a prop- 
erly prepared solution is available. In individuals 
of ordinary size, 20 to 30 grams is enough to re- 
lieve the acidosis beyond the danger point. 

Dr. Sturgis: Dr. Tobias, what was your reason 
for using sodium lactate in this patient? 

Dr. Tobias: Sodium lactate has been recom- 

mended because of the slow liberation of the so- 
dium ion in contrast to sodium bicarbonate, where 
the sodium is very rapidly split off from the bi- 
carbonate radical. Supposedly, the danger of the 
possible production of alkalosis is much less with 
sodium lactate than with sodium bicarbonate. 

Dr. Conn : In the 10 per cent of diabetic coma 
cases where inorganic acidosis is important, sodium 
bicarbonate should be given because one needs 
something that brings up the pH quickly. 

Dr. Bert Bullington : The use of sodium lac- 
tate is reputed to be harmless and it can be given 
safely in most instances. I have seen, however, three 
instances where it was given intravenously to pa- 
tients with severe diabetic coma who were in pro- 
found shock. These individuals did not respond but 
developed hyperpyrexia and had a fatal termination. 
I wonder if this reaction is due to the specific dy- 
namic action of the drug itself or to some other 
factor? Because of this I also believe it is prob- 
ably inadvisable to give large doses of sodium lac- 
tate to individuals with circulatory collapse. 

Dr. Conn : The cause of the hyperpyrexia is not 
known. I would hazard a guess that changes in the 
pH of the cells of the thermal center in the mid-brain 
upset the normal temperature regulating mechanism 
just as they upset the respiratory center and cause 
the well known Kussmaul respirations. 

References 

1. Conn, J. W. : Treatment of diabetic coma. Am. Jour. 

Med. Sci., 192:23, 1936. 

2. Gottsegen and Wittman: Untersuchungen iiber Leuko- 

cytose; Wirkung der Acetonkorper auf das weisse Blut- 

Z. Ges. Exp. M“d. 97 ( 21 : 167 , 1935. 

3. Hartman, A. F., and Darrow, D. C. : Chemical changes 
occurring in the body as a result of certain diseases : 
composition of plasma in severe diabetic acidosis and 
changes taking place during recovery. Jour. Clin. In- 
vest.. 6:257, 1928. 

4. Marble, A.. Root, H. F., and White. P.: Diabetic coma. 
New Eng. Jour. Med.. 212:288. 1935. 


February, 1939 


141 


EDITORIAL 


THE JOURNAL 

OF THE 

Michigan State Medical Society 


PUBLICATION COMMITTEE 


A. S. BRUNK, M.D., Chairman Detroit 

F. T. ANDREWS, M.D Kalamazoo 

T. E. DeGURSE, M.D Marine City 

ROY H. HOLMES, M.D Muskegon 

J. EARL McINTYRE, M.D Lansing 


Editor 

J. H. DEMPSTER, M.A., M.D. 
5761 Stanton Avenue, Detroit, Michigan 


Secretary and Business Manager of The Journal 
L. FERNALD FOSTER, M.D. 

Bay City, Michigan 


Executive Secretary 
WM. J. BURNS. LL.B. 

2642 University Avenue, St. Paul, Minnesota 
or 

2020 Olds Tower, Lansing, Michigan 


FEBRUARY, 1939 

" Every man owes some of his time to the up- 
building of the profession to which he belongs ” 

— Theodore Roosevelt. 


EDITORIAL 

GROUP MEDICAL SERVICE AND 
GROUP HOSPITAL INSURANCE 

'"pHE special meeting of the House of 
Delegates held in Detroit on January 
8 is probably one of the most momentous 
and important meetings of this deliberative 
body in the history of Michigan medicine. 
Two major items came up for consideration, 
namely, ( 1 ) group hospital care and 
(2) group medical service for those whose 
incomes are $1,500 a year or less. Group 
hospital service is beyond the experimental 
stage. It has been widely adopted through- 
out the United States and Canada. We have 
commented from time to time on group hos- 
pital care, taking the viewpoint that it is 
to the great advantage of both patient and 

142 


physician, and particularly the former, who, 
by the payment of comparatively small an- 
nual stipend, is assured hospital care in 
the case of a catastrophic illness, or any 
sickness that may call for confinement in 
a hospital. The financial advantage to the 
doctor consists in the fact that, with the 
hospital charges out of the way, the patient 
is in a much better position to meet his 
obligation to his physician. The principle 
was endorsed by the House of Delegates. 
The future will consist in its application 
and no doubt certain changes will be neces- 
sary from time to time to meet unforeseen 
circumstances. 

The adoption of group medical care is an 
innovation that may not have been antic- 
ipated by many members of the profession. 
The council of the society, however, have 
been impressed with its necessity and also 
the necessity of leadership on the part of 
doctors who render this service. 

In the plan of medical service, what is 
termed a unit system was recommended. 
For a certain specified sum to cover a 
specified period of time, the employed mem- 
ber will be entitled to a definite number of 
units of service. He may not require to 
make use of any of these units of service 
during the period of insurance. Should 
he, however, require a major operation, a 
definite number of units will be appropriat- 
ed to this type of service. The house and 
office visits will, of course, call for much 
fewer number of units. To be more spe- 
cific, if each family is entitled to a thousand 
units a year, a major operation for any 
member of the family might call for from 
150 to 200 units, which would leave a bal- 
ance of 850 or 800 to take care of any 
other illness in the family. The doctor’s 
fee for the performance of a major opera- 
tion would correspond to the number of 
units set apart for the operation. Or for 
the term units, we might use the term dol- 
lars. Thus under such a system, the in- 
surance would take care of the cost of 
medical care. Group hospital and group 
medical insurance are made possible by the 
fact that large employed groups will pay 
into a fund, but those requiring medical 
and surgical care will probably be no great- 
er in number than those requiring it under 
the individualistic system that has prevailed. 

The reader will realize that any method 
of practice that is largely untried in its 

Jour. M.S.M.S. 


EDITORIAL 


beginning will require certain modifications 
to meet unforeseen exigencies that may 
arise. It is sufficient, however, to record 
that the House of Delegates has also en- 
dorsed the principle of group medical serv- 
ice. Of course, this does not take care of 
the indigent sick whose illness will require 
to be met, either at the taxpayers’ expense 
or through certain charity as in the past. 
Group medical service and group hospital 
service can of necessity apply only to those 
who have earning power and are in a posi- 
tion to meet the annual cost, however small. 

The upper limit of income has been 
placed at $1,500. A change in this limita- 
tion of income may be advisable, depending 
upon the economic condition of the future. 
Group medical service is not socialized or 
state medicine. It is simply the sick and 
accident (non-industrial) insurance princi- 
ple made available to low income groups at 
a price they can afford to pay. The provi- 
dent in the higher income brackets have met 
and will continue to meet catastrophic or 
other illness by paying premiums into the 
old established commercial sick and accident 
insurance companies. Under group medical 
service the entire cost will be met by the 
groups themselves. 


AND YET WE ARE UNDER 
CENSURE 

T^VERY member of every county medical 
' society in the United States is a mem- 
ber or fellow of the American Medical As- 
sociation or is eligible to become a member. 

The New York Times of January 7 con- 
tained the following interesting news item 
from the Surgeon-General Thomas Parran 
of the United States Public Health Service. 
Public health in the United States, we are 
told, has advanced more in the last two 
years than ever before within a comparable 
period. To quote: “The death rate fell 

from- 11.3 a thousand in 1936 to 10.9 in 
1937, and the first six months of 1938, fell 
to 10.8, against 11.8 in that period of 1937. 
Infant mortality fell from 57.1 a thousand 
live births in 1936 to 54.4 in 1937 and only 
forty-six mothers in 10,000 died in child- 
birth, against fifty-three in 1936. Diseases 
showing a mortality decline in 1937 were 
tuberculosis, typhoid, scarlet fever, diph- 
theria, malaria, pellagra, nephritis, and 
puerperal fever. Smallpox cases rose by 

February, 1939 


4,000 to a 11,673 total in 1937, the most 
since 1931, but they were generally of a 
mild, non-virulent type, with relatively few 
deaths.” 

All this, however, has been accomplished 
under the traditional methods of medical 
practice. The Public Health Departments, 
either city, state or national, would be help- 
less were it not for the cooperation of the 
practicing physician who is the soldier at the 
outposts of illness, if we may use a mixed 
metaphor. The medical profession is aware 
that the highest achievement has not yet 
been attained in the eradication of disease 
but the fight is still on. Dr. Parran de- 
plores what he considers a fact that 40 mil- 
lion people in the United States, the lower 
economic third of the population, are un- 
able to provide themselves with medical 
care in serious illness, and he claims that 
the country is 360,000 hospital beds short. 

The medical profession of Michigan can- 
not be accused of unwillingness to cooper- 
ate in the matter of medical care. The final 
act of the special meeting of the House of 
Delegates of the Michigan State Medical 
Society, reported elsewhere, is a foreward 
movement in securing medical attention to 
the percentage of the forty million who 
belong to the state of Michigan and who 
come within the lower income brackets. 

Up to the present time, the American 
Medical Association and its constituent 
state medical societies have put forth every 
effort possible in the way of improving the 
medical training of its members as well as 
advancing the standards of the medical 
practice in the United States. The Asso- 
ciation has been foremost in the matter of 
standardization of hospitals, of insuring 
purity in drugs, and of fostering the high- 
est ideals in education; and the result has 
been that described in the Surgeon-Gener- 
al’s report. 


HONESTY 

/ T 1 HIS is the title of a new book by a doc- 
■*" tor, namely, Dr. Richard C. Cabot, of 
Boston. The subject is very interesting, one 
on which everyone has an opinion, but it is 
like the weather, very few write about it. Dr. 
Cabot says in the book that he has come 
across only one other work with the same 
title. In evaluating the importance of hon- 
esty as the king of virtues and the life-saver 

143 


EDITORIAL 


of men, Dr. Cabot goes on to say that abol- 
ish deceit and there would be no forgery, 
bribery, stealing, embezzlement, burglary, 
plagiarizing, sabotage, arson or bombing, 
cheating, by students, politicians or servants, 
false weights or measures, adulteration, 
swindling, counterfeiting, grafts, malfeas- 
ance or “rackets,” false advertising or 
quackery, blackmailing, tax-evasion, flattery 
and hypocrisy, backbiting, “propaganda,” 
spying and betrayal, treason or conspiracy, 
trapping and ambushing, smuggling, carry- 
ing of concealed weapons, kidnapping, few 
murders or poisonings, no illegal sales of 
liquor and drugs, adultery, and bigamy, few 
sex crimes or vices of any sort and no per- 
jury. It would seem that Dr. Cabot has 
included in this list about all the sinister 
acts of which mankind might be guilty. 

The book goes into the subject of honesty 
very thoroughly and discusses it in connec- 
tion with war and crime, government, in- 
dustry, science, education, medicine, re- 
ligion, and a number of other departments 
of human activity. While the entire book 
is intriguing, Dr. Cabot’s discussion of 
truthfulness in medicine is of particular in- 
terest. He puts it rather boldly that the 
truth should be told the patient at all times 
without any attempts at equivocation. In 
perusing his chapter, the thought comes to 
one as to whether a doctor knows the truth 
in its entirety and that he might be assum- 
ing a great deal in pronouncing a patient’s 
doom that might not be warranted. In 
thirty years of practice, the editor has never 
heard a doctor tell a patient he had only a 
brief time to live; although how many of 
us have been confronted by the patient who 
said that his doctor gave him up to die sev- 
eral years before. It seems not in a doc- 
tor’s interest to pronounce anyone’s doom. 
If he is a defeatist, he should not be prac- 
ticing medicine. It is heartless to destroy 
a patient’s last hope. 

The subject of honesty is a very large one 
and we can imagine that a tactless person 
who claimed to be one hundred per cent 
honest might find himself enjoying his own 
society unmolested by anyone else. He 
spends a social evening at the home of a 
friend when the hostess calls upon her 
daughter to entertain him with musical 
selections. The playing might be indiffer- 
ent, but if the guest is asked how he likes 
it and replies, “Rotten!” he may be tell- 

144 


ing the exact truth, but if he cultivates 
this social or anti-social attitude, he will 
find himself like Barney Google in the old 
song, keeping company with his horse. Of 
course, Dr. Cabot would not be so abrupt, 
yet he would not say anything to encourage 
where there was no promise. 

Dr. Cabot represents one extreme, Dale 
Carnegie the other. By this we do not 
mean that one represents pure and unadul- 
terated truth and the other the opposite. As 
much as has been said in derision of Dale 
Carnegie, we have a furtive feeling that his 
principles put into practice will go a long 
way towards greasing the social gears and 
placing sand on the rails. 

We commend Dr. Cabot’s book, however, 
as it contains a great deal of food for 
thought. It is a serious discussion of a 
great subject. 


A Fine Decision 

(The Detroit Free Press) 

At a meeting Sunday in Detroit the House of 
Delegates of the Michigan State Medical Associa- 
tion adopted the principle of group hospital service 
and group medical service for persons with incomes 
of less than $1,500 a year. 

The details of its plan to bring medical and hos- 
pital care within easier reach of more than 2,000,000 
people have yet to be worked out. 

The Legislature will be asked to permit the or- 
ganization of Hospital and Medical Security, Inc., 
as a nonprofit corporation empowered to sell health 
insurance to eligible groups. 

A tentative explanation of what it is believed this 
will mean to the public needing hospitalization has 
been given out. Supporters of the plan think that 
sixty cents a month for a single subscriber, or 
$1.25 for a family, would provide care in a ward, 
and that semi-private care could be had for 75 
cents to $1.75 a month. 

These payments would entitle a subscriber to 21 
days of hospital care in the first year, to 23 days 
in the second year, and so on up to 30 days for 
the fifth and subsequent years. 

General nursing service, operating and delivery 
rooms as often as necessary, surgical dressings and 
plaster casts w T ould be included. 

A somewhat similar plan is contemplated for per- 
sons who need medical care but do not have to 
go to a hospital. 

And it is hoped that in time indigent and semi- 
indigent groups may be able to get similar service 
through arrangements between Hospital and Med- 
ical Security and their communities. 

The Michigan State Medical Association shows 
by its action that its members are imbued with the 
finest tradition of their profession, which is to save 
life and relieve suffering without regard to the race, 
creed or financial condition of those who need their 
services. 

A good many people in Michigan, who have gone 
without adequate medical and hospital attention be- 
cause they were too proud to accept what they 
could not pay for, will welcome this tangible plan 
for relief from one of their greatest worries. 

Jour. M.S.M.S. 



J T IS still too early to convey much information on the details of 
the epoch-making action of the House of Delegates on January 8, 
1939. The action of the House of Delegates has been extremely 
favorably received by the general public and, regardless of what you 
personally think, public feeling molds actions. 

Profound, and we fear detrimental, changes in the care of the 
sick citizen, are planned by bureaucratic governmental agencies. 
Organized medicine resents the aged and sick being used as “guinea 
pigs” for governmental socialized experimentation. 

Our Society is a truly democratic organization with a membership 
of over 4,000 “rugged individualists.” It cannot be expected that 
action of the House of Delegates will meet with unanimous approval. 
Good sportsmanship and an interest in the future of medical service 
are depended upon to assure a wholehearted acquiescence in the final 
decision. 


“It ain’t the individual, nor the army as a whole, 

But the everlastin’ teamivork of every bloomin’ soul.” 


Yours truly, 



President, Michigan State Medical Society 


February, 1939 


145 


DO NOT FORGET YOUR POSTGRADUATE PROGRAM FOR 1939 

“A few physicians increase in knowledge from within and grow from their own 
doing. These are the innate investigators. The rank and file require outside 
help to grow and to progress. Books, meetings, contacts, discussions, teachers, 
are our armamentarium for progress. Like the ‘spring tonic’ of past days, all of 
us need some of this medicine at least annually, better if it comes more frequently. 
A large majority of physicians know their need and seek treatment.” — Henry A. 
Christian, M.D. 


POSTGRADUATE PROGRAM FOR 1939 
Ann Arbor and Detroit 


Courses 

Anatomy Wednesdays, 1 :00-10 :00 p. m. 

Electrocardiographic Diagnosis 

Urology 

Proctology 

Gynecology, Obstetrics and Gynecological Pathology 

Ophthalmology and Otolaryngology 

The Care of the Diabetic 

Pediatrics 

General Medicine 

Pathology: Special pathology of neoplasms 

Pathology of the female genito-urinary organs 
Special pathology of the eye 
Special pathology of the ear, nose and throat 
Laboratory Technic 
Clinical Courses — Summer Session 
Roentgenology 
Roentgenology 

Neuropsychiatry (Administrators’ and Specialists’ Course) 
Neuropsychiatry 


All dates inclusive 
February 15 — May 31 
April 3-8 
April 10, 11 and 12 
April 13, 14 and 15 
April 10-14 
April 20-26 
May 8, 9 and 10 
June 5, 6 and 7 
June 19-23 
June 26- July 7 
July 10-21 
July 24- August 4 
August 7-18 
June 26- August 4 
June 26- August 4 
June 26-August 4 
October 30-Nov. 4 
April 3 and 4 
November 1, 2 and 3 


EXTRAMURAL POSTGRADUATE COURSE 

continuing throughout week of April 24 


Beginning April 3 and 

Ann Arbor 
Battle Creek-Kalamazoo 
Flint 

Grand Rapids 


Lansing- Jackson 
Saginaw 

Traverse City-Manistee- 
Cadillac-Petoskey 


Further information will be given in the postgraduate bulletin and in subse- 
quent numbers of The Journal of the State Medical Society. 


DEPARTMENT OF POSTGRADUATE MEDICINE 
University Hospital, Ann Arbor, Michigan 


146 


Jour. M.S.M.S. 



♦ 


Department of Economics 

L. Ferxald Foster, M.D., Secretary 


♦ 


MICHIGAN ANSWERS 
THE CHALLENGE 

A^EDICAL care for all the people of 
Michigan at a price they can afford 
to pay has been the objective of the Mich- 
igan State Medical Society for a number of 
years. Surveys over the past five years 
have provided sufficient data to permit of a 
definite set of proposals to effect the desired 
objective. 

In reviewing the various groups of our 
social order we find three major groups — 
the economically comfortable, those of mod- 
est income and the medically indigent. The 
first group has always been able to purchase 
the necessities of life, including medical 
care, to the extent of its desires. The 
medically indigent group is the direct re- 
sponsibility of government. This leaves only 
one group — those of modest income — for 
whom health services should be provided 
at a price it can afford to pay. This pro- 
vision is necessary only on occasions of 
catastrophic illness. To this group the 
Michigan State Medical Society now ex- 
tends health services on a voluntary insur- 
ance basis, a basis covering hospitalization 
and professional services. 

Voluntary group hospitalization is not a 
new proposal. It is in vogue in a number 
of states and communities and has served 
to solve only part of the problem. Voluntary 
group medical service is a new venture, but 
one that rounds out a complete service for 
a needy group of our citizenry. 

If sl change is indicated in the adminis- 
tration of our health needs we should 
analyze carefully the results of our present 
democratic American manner of health 
service. We should compare our present 
results with those of other countries from 
which there is a tendency to take example. 
We point with pride to our medical re- 
search and scientific advancement. We 
cherish our life expectancy span and our 
mortality rates. We view with extreme sat- 
isfaction the incidence of preventable dis- 
eases in this country. Under our present 
system we have a minimum of malingering 

February, 1939 


and a low per diem rate of hospitalization 
as compared with our European neighbors 
with federalized forms of health adminis- 
tration. 

When we discuss with the laity the ques- 
tion of health services it is obvious that the 
quality of American medical care is taken 
for granted and does not carry a true inter- 
est appeal. When, however, we translate 
medical care in terms of taxes the laity im- 
mediately manifests a true interest — an in- 
terest developed through recent years of 
tax consciousness. 

If those insidious forces which clamor for 
a departure from the American way of ren- 
dering health services are sincere in seeking 
a solution for the only needy group — those 
of modest income ; those whose incomes fall 
in the low brackets — then Michigan has the 
answer. This answer does not involve a 
departure from our democratic principle of 
free choice of physician; neither does it 
invoke the development of socialistic, 
bureaucratic control ; it does not involve 
huge sums of public funds; nor will it act 
as a deterrent force upon the great scien- 
tific advancement of American Medicine — 
an advancement second to none in the 
world. It preserves all that is desirable in 
our present methods and effectually renders 
to all our people the finest quality of med- 
ical service at a price they can afford to pay. 
The answer to the challenge is embodied 
in the views of the Michigan State Medical 
Society : 

1. The economically comfortable individ- 
ual should purchase his health services 
to the extent of his wants. 

2. The medically indigent individual 
should be the responsibility of govern- 
ment. 

3. The individual of modest income 
should avail himself of low cost volun- 
tary group hospitalization and volun- 
tary group medical service. 

Let’s do it in the democratic American 
way. 


147 


DEPARTMENT OF ECONOMICS 


GROUP HOSPITALIZATION AND 
GROUP HEALTH SERVICE 

T HE House of Delegates of the Michigan 
State Medical Society in special session 
approved the principles of voluntary group 
hospitalization and voluntary group med- 
ical sendee. It authorized The Council to 
proceed with development of detailed plans 
consistent with the adopted principles. 

Group Hospitalization, now in vogue in 
several states, allows a subscriber to pur- 
chase a given number of days of hospital 
services (exclusive of any professional serv- 
ices) for a moderate premium payment. 

Group Medical Service, an entirely new 
procedure, enables a subscriber to purchase 
units of medical service, such units to in- 
clude all the services rendered by Doctors 
of Medicine in all the specialties. 

The action of the House of Delegates 
calls upon The Council to develop its plans 
in cooperation with the Michigan Hospital 
Association, labor, industry, agriculture, 
religious and educational groups, commu- 
nity councils and other interested groups. 
It is recognized as a joint responsibility of 
both the community and the medical profes- 
sion to bring adequate hospital and medical 
services within the reach of the low-income 
group of the community. 

The medical profession is asked to recog- 
nize the importance of the adoption of the 
broad basic principles and to bear in mind 
that the development of the minute details is 
of lesser importance. In the development 
of details the interests of the patient and of 
the medical profession will at all times be 
guarded. Since The Council of the Mich- 
igan State Medical Society represents in a 
democratic manner the forty-two hundred 
members of the State Society, the latter’s 
interests and views will be reflected in all 
deliberations. 


WOULD IT BE TIMELY? 

THE Detroit Free Press asked the above 
pertinent and important question in the 
following editorial, published on Januarv 
25 , 1939 : 

“The President has sent the report of his special 
committee of public health and welfare to Congress 
for study and action. 

“The report recommends, among other things, a 
Federal-State public health program to cost $850,- 
000,000 a year. 


“Admitting, as it must, that good health is a per- 
sonal and national asset, Congress will have to de- 
cide whether, taking into account the tremendous 
burden of debt Mr. Roosevelt has imposed on the 
country for other purposes, spending $850,000,000 a 
year for the improvement of public health is either 
financially expedient or necessary, at this time. 

“The United States is the healthiest country of 
comparable size and population in the world. 

“A few weeks ago the annual report of the Sur- 
geon General showed that the American people 
have steadily improved in health, without the as- 
sistance of any such expensive program of public 
aid. 

“The health of the people is much better than the 
health of business, which has been bled white by 
governmental extravagance and waste. 

“With the medical profession constantly striving 
to improve the public health, and achieving remark- 
able results, would it be wise to spend billions of 
public funds for health measures, at a time when 
the country needs nothing else so much as relief 
from debt and taxes? 

“Would it not be wiser to stop spending and help 
business and employment back to their feet and thus 
enable the people to pay for their own medical care 
out of the incomes now denied them by economic 
stagnation and chronic unemployment? 

“A thorough study of the problem which Mr. 
Roosevelt has tossed into the lap of Congress in- 
volves finding answers to those questions.” 


COUNCIL AND COMMITTEE MEETINGS 

1. Wednesday, December 28, 1938 — Maternal 
Health Committee — Hotel Statler, Detroit 
— 12 :30 p. m. 

2. Friday, January 5, 1939— Advisory Committee on 
Syphilis Control — Hotel Statler, Detroit — 

3. Saturday, January 7, 1939 — Committee on Dis- 
tribution of Medical Care — Hotel Statler, De- 
troit — 2 :00 p. m. 

4. Saturday, January 7, 1939 — The Council — Hotel 
Statler, Detroit, 6:30 p. m. 

5. Sunday, January 8, 1939- — The Council — Hotel 
Statler, Detroit— 8 :00 p. m. 

6. Sunday, January 15, 1939 — Legislative Commit- 
tee — Hotel Olds, Lansing — 4:00 p. m. 

7. Thursday, January 19, 1939 — Mental Hygiene 
Committee — Eloise Hospital, Eloise — 6:00 p. m. 

8. Sunday, January 22, 1939 — Advisory Committee 
to Woman’s Auxiliary — Bancroft House, Sag- 
inaw — 11:00 a. m. 

9. Sunday, January 22, 1939 — Preventive Medicine 
Committee — Hotel Statler, Detroit — 2 :00 p. m. 

10. Sunday, January 22, 1939 — Legislative Commit- 
tee — Hotel Olds, Lansing — 2 :00 p. m. 

11. Sunday, January 22, 1939 — Committee on Scien- 
tific Work — Hotel Olds, Lansing — 3 :00 p. m. 

12. Saturday and Sunday, January 28-29, 1939 — Mid- 
winter Meeting of The Council — Hotel Statler. 
Detroit. 

13. Monday, February 6, 1939 — Cancer Committee 
— Woman’s League Bldg., Ann Arbor — 6:30 p. m 


148 


Jour. M.S.M.S 


MICHIGAN STATE MEDICAL SOCIETY 

Proceedings of House of Delegates 

Special Session 
Statler Hotel, Detroit, Michigan 
January 8, 1939 


TABLE OF CONTENTS 

1. Roll Call 149 

2. Speaker’s Address 150-161 

3. President’s Address 150-161 

4. President-Elect’s Greetings 152 

5. Report of the Council 152-161-165 

6. Report of Committee on Distribution of 

Medical Care 153-162 

7. Resolution of Support to AMA 159-161 

8. Resolution Authorizing The Council re 

Finances 160-161 

9. Motion re Enabling Legislation 165 

10. Election of Alternate Delegate to AMA.... 165 

11. Vote of Thanks to Ralph H. Pino, M.D.... 165 


ROLL CALL 


COUNTY DELEGATE 


SESSION 
Morn- After- 
ing noon 


1. Allegan E. T. Brunson, M.D. x 

2. Alpena-Alcona- 

Presque Isle F. J. O’Donnell, M.D. x 

3. Barry Robert B. Harkness, M.D. x 

4. Bay-Arenac- 

Iosco-Gladwin R. C. Perkins, M.D. x 

5. Berrien 

6. Branch 

7. Calhoun Harvey Hansen, M.D. x 

A. T. Hafford, M.D. x 

8. Cass K. C. Pierce, M.D. x 

9. Chippewa- 

Mackinac F. W. Mertaugh, M.D. x 

10. Clinton 

11. Delta- 
Schoolcraft 

12. Dickinson-Iron E. M. Libby, M.D. x 

13. Eaton Paul Engle, M.D. x 

14. Genesee Frank E. Reeder, M.D. x 

Donald R. Braise, M.D. x 

Robert Scott, M.D. x 

15. Gogebic 

16. Grand Traverse- 
Leelanau-Benzie 

17. Gratiot-Isabella- 

Clare Myron C. Becker, M.D. x 

18. Hillsdale L. W. Day, M.D. x 

19. Houghton- 
Baraga- 

Keweenaw G. M. Waldie, M.D. x 

20. Huron-Sanilac 

21. Ingham R. L. Finch, M.D. x 

C. F. DeVries, M.D. x 

H. W. Wiley, M.D. x 

22. Ionia-Montcalm R. R. Whitten, M.D. x 

23. Jackson Philip A. Riley, M.D. x 

James J O’Meara, M.D. x 

24. Kalamazoo-Van 

Buren R. J. Hubbell, M.D. x 

Fred M. Doyle, M.D. x 

I. W. Brown, M.D. x 

25. Kent A. V. Wenger, M.D. x 

C. F. Snapp, M.D. x 

P. W. Kniskern, M.D. x 

G. H. Southwick, M.D. x 

W. R. Torgerson, M.D. x 

26. Lapeer Herbert M. Best, M.D. x 

27. Lenawee A. W. Chase, M.D. x 

28. Livingston H. Huntington, M.D. x 

29. Luce 

30. Macomb R. F. Salot, M.D. x 


x 

x 

X 


X 


X 

X 


X 

X 

X 

x 

x 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 


February, 1939 


31. 

32. 

33. 

34. 


35. 

36. 

37. 

38. 

39. 

40. 

41. 


Manistee E. A. Oakes, M.D. 

Marquette-Alger Vivian Vandeventer, M.D. 
Mason 

Mecosta-Osceola- 

Lake G. H. Yeo, M.D. 

Menominee 

Midland 

Monroe D. C. Denman, M.D. 

Muskegon E. N. D’Alcorn, M.D. 

L. E. Holly, M.D. 


Newaygo 

Northern 

Michigan G. B. Saltonstall, M.D. 

Oakland Otto O. Beck, M.D. 

Palmer E. Sutton, M.D. 
Zea Aschenbrenner, M.D. 


42. Oceana 

43. O.M.C.O.R.O. 

44. Ontonagon 

45. Ottawa 

46. Saginaw 

47. Shiawassee 

48. St. Clair 

49. St. Joseph 

50. Tuscola 

51. Washtenaw 


52. Wayne 


53. Wexford 


C. R. Keyport, M.D. 

A. E. Stickley, M.D. 
Clarence E. Toshach, M.D. 
L. C. Harvie, M.D. 

A. L. Arnold, Jr., M.D. 

A. L. Callery, M.D. 

T. E. Hoffman, M.D. 

John A. Wessinger, M.D. 
Dean W. Myers, M.D. 

L. J. Johnson, M.D. 

T. K. Gruber, M.D. 

J. M. Robb, M.D. 

C. E. Umphrey, M.D. 

R. H. Pino, M.D. 

E. D. Spalding, M.D. 

R. M. McKean, M.D. 

R. L. Novy, M.D. 

A. E. Catherwood, M.D. 
W. D. Barrett, M.D. 

G. C. Penberthy, M.D. 

R. C. Jamieson, M.D. 

C. E. Simpson, M.D. 

C. S. Kennedy, M.D. 

H. F. Dibble, M.D. 

A. P. Biddle, M.D. 

C. E. Dutchess, M.D. 
Warren B. Cooksey, M.D. 
Wm. J. Stapleton, Jr., M.D. 
P. L. Ledwidge, M.D. 

C. E. Lemmon, M.D. 

C. K. Hasley, M.D. 

J. A. Hookey, M.D. 

C. F. Brunk, M.D. 

S. W. Insley, M.D. 

L. J. Bailey, M.D. 

R. L. Laird, M.D. 

Allan McDonald, M.D. 

C. F. Vale, M.D. 

H. L. Clark, M.D. 

F. W. Hartman, M.D. 

C. D. Benson, M.D. 

G. L. McClellan, M.D. 

S. E. Gould, M.D. 

L. O. Geib, M.D. 

Wm. P. Woodworth, M.D. 
W. Joe Smith, M.D. 


x 

X 


X 


X 

X 

X 


X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 


X 

X 


X 


X 

X 

X 


X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 


SUNDAY MORNING SESSION 

January 8 , 1939 

A special meeting of the House of Delegates of 
the Michigan State Medical Society was held at the 
Statler Hotel, Detroit, Michigan, at ten thirty-five 
o’clock, Dr. Philip A. Riley, the Speaker, presiding. 

The Speaker: The Special Session of the Michi- 
gan State Medical Society House of Delegates will 
now come to order. 

Mr. Secretary, will you read the call for the Spe- 
cial Session? 

The Call for the Special Session was read by the 
Secretary, Dr. L. Fernald Foster. 


149 


SPECIAL SESSION— HOUSE OF DELEGATES 


The Speaker: Gentlemen, you have heard the 

call for the Special Session. 

Dr. Ledwidge, as Chairman of the Credentials 
Committee, will you give us a report? 

Dr. P. L. Ledwidge (Wayne County) : I have 

here the credentials of sixty-eight delegates who 
have been certified by the Credentials Committee. 

I move that they be accepted as the official roll 
call. 

The Speaker: There has been a motion made 

that sixty-eight constitute the roll call. Is there a 
second to that motion? 

The motion was seconded by Dr. Andrew P. 
Biddle of Wayne County and carried. 

The Credentials Committee presented several spe- 
cial cases; the House of Delegates voted on the eli- 
gibility of these delegates, in accordance with the 
By-laws. 

The Speaker: The Reference Committees which 
were appointed last September will hold over for 
this Special Session. 

Vice Speaker Martin H. Hoffman took the chair. 

The Vice Speaker: We will now hear the ad- 
dress of the Speaker of the House, Dr. Philip A. 
Riley. 

SPEAKER’S ADDRESS 

Dr. Riley read the address of the Speaker. 

Mr. President, President-Elect, Councillors and 
members of the House of Delegates : 

This is my first occasion to wish you all a Happy 
New Year and I do so from the bottom of my 
heart. I feel that during the year of 1939 many of 
our problems will be brought to a conclusion. Dur- 
ing the past year, in spite of bewilderment, confu- 
sion of ideas and chaos, great strides forward have 
been made. 

At our September meeting of last year, the Com- 
mittee on the Distribution of Medical Care brought 
in a summary of a tremendous amount of work. 
Certain principles of this summary were approved 
and certified for further study. You voted at that 
time to have this committee bring in a report of 
further work done at a special meeting in the near 
future. We are here today for purpose. 

If you remember, at cur meeting in September, 
we were a bit confused as to what course we 
should follow, and as to what action we should 
take. The medical profession of the entire country 
were in the same boat with us. The A.M.A. had 
called a special meeting of its House of Delegates 
and it was less than three months after the time of 
the regular meeting. A conference had been called 
in Washington to help solve these problems. Hos- 
pital insurance had taken on a sudden growth and 
words of praise were all that could be heard for 
the idea. Various organizations were clamoring for 
a plan for the prepayment of medical care. These 
organizations ranged from CIO Unions to the com- 
mittee of 400. 

Since our meeting in September, many changes 
have taken place. I think probably the most signifi- 
cant change has effected the doctors themselves. 
We have lost the jitters, or, in other words, we 
have regained confidence in ourselves and our own 
ability on how to run our own business. We have 
awakened to the fact that we know more about our 
own business than do the synthetic secretaries at- 
tached to political band wagons. 

Since our meeting in September, hospital insurance 
has taken on further growth to the point where to- 
day it is as much a part ot our natural life as fire 
and theft insurance. It protects the individual 
against catastrophy the same as fire insurance does. 

Since our meeting in September, we have had a 
national election with the conservative element com- 


ing rapidly to the front and in the last few weeks 
the economic index of the country has greatly im- 
proved. While long overdue, nevertheless the im- 
provement has come. The economic situation of the 
country is the most vital factor of all when we talk 
about medical economics. The people of this coun- 
try are inherently honest and will avail themselves 
of adequate medical care when economic conditions 
provide the men with jobs. 

During the past year several commercial compa- 
nies have entered the field of sickness indemnity. 
The price of the policies vary from four cents a 
day to seven cents a day. Some of these com- 
panies will pay the patient in cash while others will 
pay the doctor. It remains to be seen which is the 
best plan. Various State Medical Societies, such as 
California, Wisconsin and New York have entered 
the field of sickness insurance. I am not familiar 
with the details of their plans but no doubt they 
have their good and bad points. 

Following the recommendation of the House of 
Delegates in September our own committee on the 
Distribution of Medical Care, headed by Dr. Pino, 
have done a tremendous amount of work along this 
line. We are here today to hear their report. We 
have several courses left open to us. We can adopt 
it as it stands or we can adopt it with amendments 
to it. We can flatly reject it or we can approve part 
of it and send it back to the committee for further 
study. We can approve it and send it to our mem- 
bership for a referendum vote, and, lastly, we can 
accept the report and put it on the shelf. I sincerely 
hope that this last procedure is not resorted to. 
To do such a thing would be a great miscarriage of 
effort and go down in our records as another 
“Love’s Labor Lost.” 

(Applause) 

The Vice Speaker: The Speaker’s Address will 
be referred to the Reference Committee on Officers’ 
Reports. 

Dr. Frank E. Reeder (Genesee County) : T rise 
at this occasion to ask if it w r ould not be proper, as 
was done in the House of Delegates at Chicago, to 
permit all members of the profession to sit in at this 
meeting. We have been approached by members of 
the profession who are not delegates who desire to 
listen in, and I think they are entitled to do so. 
Whether it requires any action or not, I do not 
know, but it would seem to me it is the right thing, 
gentlemen, for us to do. 

The Vice Speaker: The Chair would rule that 
is a matter for the House’s consideration and would 
entertain a motion to that effect. 

Dr. Andrew P. Biddle (Wayne County) : I 

make that motion. 

The motion was seconded and carried. 

The Vice Speaker: The gentlemen and ladies, if 
there be any, may be seated for the session. 

The Vice Speaker: The next order of business 
is the address of your President, Dr. Henry A. Luce. 
(Applause) 

PRESIDENT’S ADDRESS 

President Luce: Mr. Vice Speaker, Members of 
the House of Delegates, and Guests : 

At the onset, your president desires to express 
his tribute — and in this he feels that he is express- 
ing the feelings of the entire organization — to the 
members of the committee, to those who have not 
officially been members of the committee, to the 
officers of the society, to the executive secretary, 
and to all their assistants for the efforts that have 
been expended and the sacrifices that have been 
made in the preparation of subject matter to be 
presented to this group. 

I also have a pardonable pride in the attitudes and 

Tour. M.S.M.S. 


150 


SPECIAL SESSION— HOUSE OF DELEGATES 


motivations of the entire group here assembled. 
You have come here today at your own expense, to- 
gether with the coincident loss of income entailed 
with your absence from your fields of labor. For 
what purpose? Not a selfish motive, not an econom- 
ic one, but for the purpose of making a contribu- 
tion to the health of the community. Even more 
than that, there are involved other implications that 
affect our political integrity. They involve our much 
cherished American democracy. Shall individualism, 
self-responsibility and free enterprise be maintained, 
or shall compulsory regulation and regimentation 
be instituted? Shall the determination of medical 
care for the low income group be a matter of gov- 
ernmental regulation or shall it become a function 
of private communities? 

Your president at this point wishes to express his 
keen appreciation and that of the Michigan State 
Medical Society for the portion of the recent inau- 
gural address of Governor Fitzgerald: “Plans have 
been advanced for socialized medicine calling for 
designated physicians to attend the needy. I do not 
favor this system. I believe persons in need should 
not be denied the right of selection of their own 
physicians or dentists simply because they are in 
distress. I propose that such persons be allowed to 
select their own physicians, just as you and I, and 
that the cost be met from the welfare health fund. 
In other words, I believe the patient-physician re- 
lationship should be preserved.” (Applause) 

The word “compulsory” has no place in demo- 
cratic America. The term “compulsory” brings the 
threat of Communism and Nazism with their train 
of sabotage, treason, cruelty and the indescribable 
squalor of concentration camps. 

You, as a group today, are not attacking your 
own problem or that of your patients, solely. As 
before stated, the problem is far greater and broad- 
er and it is sincerely believed that this broad view 
will be taken and met with characteristic fortitude 
and sound judgment. 

The ability to act wisely and constructively in 
difficult situations is the essence, not only of mental 
soundness, but also of statemanship and leadership. 

Groups act not unlike individuals when faced with 
difficult situations. The well-balanced, efficient per- 
son attempts to solve his problems in a frank, 
straightforward manner. He first tries to under- 
stand the facts and then faces them squarely as they 
are, no matter how disagreeable or foreboding they 
may be. Individuals dodge reality by evading re- 
sponsibilities, minimizing difficulties, bv self-justifi- 
cation through shifting of blame, and by procrasti- 
nation and rationalization. 

It is sincerely hoped and expected that this group, 
made up of intelligent, mature adults, will frankly 
and squarely face reality, and as a result will make 
decisions in which we will all abide with inexorable 
determination, safe in the knowledge that such acts 
are honest, sincere and motivated by an unselfish 
wish to make a distinct contribution to our social 
and political welfare. 

I know of no other group in which patriotism, 
high ideals and the sense of responsibility are pres- 
ent to the degree represented by our organization. 
To no other group would I leave the responsibility 
with less fear of error and un-American activities. 
“Strength to your arms and wisdom to your judg- 
ment.” 

At this time I should like to take a few minutes 
of your time to discuss a matter which I consider 
is well worth your attention. 

Recent attacks on the medical profession of the 
United States have endeavored to create the impres- 
sion that organized medicine is divided against it- 
self and that many physicians are in revolt. The 
statement is untrue. 


Organized medicine speaks through its House of 
Delegates, a democratically chosen representative 
body. At the very first meeting in which the Ameri- 
can Medical Association was founded, differences of 
opinion as to methods of procedure arose and were 
openly discussed. The democracy of that first meet- 
ing of the American Medical Association has be- 
come a tradition. The representatives of the 111,000 
members of the Association are always free to dis- 
cuss in open meeting their opinions on the various 
phases of the problems which constantly confront 
the profession. It is significant that the member- 
ship of the Association is today the greatest in its 
history and that few if any of those said to be in 
revolt have resigned their membership. 

At times differences of opinion may have given 
the impression that the doctors cannot agree among 
themselves. I leave it to you gentlemen and to a 
grateful public to decide whether organized medi- 
cine, comprising, as it does, each one of you indi- 
vidually as well as our county and state societies, 
could have reached the high plane of organized per- 
fection and prestige had we not been able in the 
long run to discuss and settle our individual differ- 
ences of opinion. 

We have been assailed by the Government of the 
United States with an indictment that we constitute 
a monopoly and that our actions through our dele- 
gated authorities in the American Medical Associa- 
tion have violated the laws of this country as they 
apply to interstate commerce and restraint of trade. 

The policies of the American Medical Association 
have been formulated by the membership of that 
Association. Had that membership at any time dur- 
ing the years I have served as a member of the 
national House of Delegates disagreed with those 
policies which I as a delegate have had a part in 
forming, I cannot make myself believe that I would 
have been returned to the national House term after 
term. I have sat in committee meetings with dele- 
gates from other states and have differed with them 
at times on what method should be pursued to the 
best interests of the American people and American 
medicine, but never has there come forth from any 
of these committee meetings, much less passed by 
the House of Delegates, any policy which I could 
not conscientiously support. 

The policies of the American Medical Association 
are the policies of the Michigan State Medical So- 
ciety and of every county society in the state of 
Michigan and in the United States. For the grand 
jury at Washington to indict five officials of cur 
national organization may be legally 7 correct. I have 
not a legal training, but my medical experience 
teaches me to treat the etiological factor at the point 
of origin. The five officials of the American Medi- 
cal Association have interpreted the actions of the 
House of Delegates of the AMA. The State Socie- 
ties have indorsed the actions of the national body. 
111,000 physicians constitute the State Socities. At 
the very least from a medical and ethical point of 
view, if the five officials of the AMA have done any- 
thing wrong, the Government should have officially 
indicted me and every other member of organized 
medicine. 

I, for one, would like to have the American peo- 
ple know that I personally as a physician feel that I 
have been indicted by the United States Govern- 
ment ; that the impugned reflection on the integrity 
of the American Medical Association is considered 
by me as a reflection upon myself. I believe that the 
rest of you feel much the same. 

I should like to have every 7 citizen of the United 
States know that his family physician has been in- 
dicted. Can you make that mother whose child’s 
life has been saved think that her doctor is a knave? 
Can the millions of people that twenty-five years 


February, 1939 


151 


SPECIAL SESSION— HOUSE OF DELEGATES 


ago would have died of typhoid, diphtheria, diabe- 
tes, cholera infantum and other diseases, who walk 
the streets to day and enjoy life’s bounty, be made 
to say that American medicine deserves indictment? 
The blind have been made to see, the lame to walk, 
and the ill restored to health under our American 
system that never has defaulted an obligation nor 
proved unfaithful to trust. 

I would like to have the American people know 
that the medical profession of this country stands 
united in opposition to this indictment and the at- 
tacks made on its integrity. We always have pre- 
sented a united front, not only in the battle for 
the best public health service for the people, but in 
the constant seeking for better ways of providing 
medical service and care. That this united front 
exists is proved by the great attainments made by 
American medicine since the American Medical As- 
sociation was created in 1847 for the initial purpose 
of improving medical education. Today our medical 
schools are the outstanding ones in the world. Our 
research centers are leading the world into new 
avenues of medical knowledge. Today the medical 
world comes to America for its postgraduate studies 
rather than American physicians going to foreign 
countries for further studies, as was true a century 
ago. A united profession has attained all of these 
things, not for themselves but for the people, and 
a united profession will continue to oppose all that 
is inimical to the welfare of the people and fight for 
those things which best serve the people’s interests. 

(Applause) 

The Vice Speaker: The President’s address will 
be referred to the Reference Committee on Officers’ 
Reports. 

The Vice Speaker will now turn the meeting back 
to the Speaker. 

The Speaker resumed the chair. 

The Speaker: We will now hear a word from 
our President-Elect, Dr. B. R. Corbus. (Applause) 

PRESIDENT-ELECT’S GREETINGS 

Air. Speaker, Alembers of the House of Dele- 
gates : I have no message to bring you. You have 
heard a very stimulating and important message 
from the President. I do feel that we have before 
us today perhaps the most important subject, coming 
at the most important time, of any meeting that we 
have perhaps ever had. I know you will meet the 
problem with your usual good judgment. 

I have tremendous faith in the House of Dele- 
gates. I have had long experience in judging the 
temper of the House of Delegates. They never yet 
have failed to approach a subject with sanity and 
judgment. It has been surprising in times gone by, 
when the House has met with important policies to 
be decided and when the Council has been con- 
cerned, because of their greater opportunities to 
face the problems which were to come up they have 
had the opportunity of further study. 

So I know that we are going to meet this prob- 
lem in the same way, in a determined way and in a 
manner which will be for the safety of the medical 
profession of Michigan and this country. I thank 
you. (Applause) 

The Speaker: Thank you, Dr. Corbus. 

We shall now hear the report of the Council by 
Dr. Paul R. Urmston, Chairman of the Council. 

REPORT OF THE COUNCIL 

Dr. Paul R. Urmston : Mr. Speaker and Mem- 
bers of the House of Delegates: The Council sub- 
mits the report that you have been looking for 
anxiously and awaiting since September. 

There has been some criticism of your officers 
that we did not call the meeting sooner, but if you 


knew the tremendous amount of work of your Com- 
mittee on Distribution of Aledical Care and the time 
spent in evolving any plan to be submitted to you 
today, you would appreciate the time and delibera- 
tion required. There should be no criticism by any 
member of the medical profession of the State of 
Afichigan for the work done by your committees. 
The committees are representatives of you, and for 
the interest of the medical profession and the public 
it takes time and many deliberations to evolve a plan 
of the importance presented to you today. 

Group Hospital Service and Group Medical Care 
Plans 

At the Seventy-third Annual Aleeting of the Alich- 
igan State Aledical Society, held in Detroit last Sep- 
tember, the House of Delegates received a consid- 
erable amount of material from the Committee on 
Distribution of Aledical Care covering the subjects 
of (a) Group Hospitalization; and (b) Group Aled- 
ical Care Plans. The House of Delegates Reference 
Committee presented the following report on the 
Committee’s activities : 

“We approve the principle of voluntary hospital 
insurance, providing that hospital insurance be so 
defined that it does not include professional serv- 
ices by a doctor of medicine. We also recognize 
the merits of certain principles in voluntary health 
insurance, and we therefore urge that Recommen- 
dation IV of the ‘General Program of Aledical 
Care’ as defined by the American Medical Asso- 
ciation, September 17, be adopted in principle by 
the Alichigan State Aledical Society. We further 
recommend that the Committee on Distribution of 
Aledical Care continue with more detailed studies 
of an acceptable insurance program — these studies 
to be presented to a special meeting of the House 
of Delegates in the near future.” 

In the past few months, the members of The 
Council have become thoroughly convinced that the 
membership of the society generally, throughout the 
state, desires to put into active operation a state- 
wide system for the prepayment of medical care and 
hospital service through the pooling of funds there- 
for. The public desire is evidenced numerous ways 
— the growth of so-called “non-profit hospital asso- 
ciations,” the Governor’s message to the Legislature 
urging group hospitalization, the pressure of com- 
munity groups and certain employers, the statements 
of labor leaders, and the unanimous endorsement by 
farm organizations, many of whom are now only 
awaiting the action which the House of Delegates 
of the Michigan State Aledical Society will take at 
this meeting to determine their own course. 

In the problem of bringing adequate hospital serv- 
ice and medical care within the reach of every 
citizen of the low-income group of the community, 
the responsibility lies primarily with the community 
itself and secondarily with the medical profession 
and allied health groups. Some have mistakenly 
supposed that the doctors of medicine had to assume 
the whole burden, furnish the plan, raise the money 
and take all the risks, put on a sales campaign and 
do all the work, medical and financial, in the public 
interest. 

By enlisting the community in such an enterprise, 
the greatest possible barrier against governmental 
interference would be built. Therefore, the Commit- 
tee on Distribution of Aledical Care presents to us 
a statewide community health service founded on 
the development of lesser community groups built 
around a board of directors chosen by interested 
groups including industry, labor, agriculture, medi- 
cine, dentistry, hospitals, education, religious organi- 
zations and other interested groups for the purpose 
of furnishing non-profit voluntary hospital service 

Jour. ALS.ALS. 


152 


SPECIAL SESSION— HOUSE OF DELEGATES 


and non-profit voluntary medical care based on the 
principles laid down in the plans developed by the 
Committee on Distribution of Medical Care. 

The purposes of this meeting are to consider and 
to act upon the proposals contained in the notice 
of the meeting. The undertaking is a large one. 
The report and exhibits of the Committee on Dis- 
tribution of Medical Care were reviewed by The 
Council at a meeting held last night; these are pre- 
sented to you in full for your consideration. 

The projected plan of group medical care contains 
several matters to which The Council directs your 
particular attention: (1) the plan is open to all li- 

censed doctors of medicine in the state who agree 
to the rules and regulations; (2) the subscribers 
have complete freedom of choice; (3) the control 
of the administration and policy of medical service 
is to be vested in the medical profession ; (4) the 
medical services are to be paid out of available 
pooled funds on a unit system. Such a system af- 
fords freedom of action, insures the success of the 
plan and if dues are not placed at a proper figure 
they can be rectified at any time. The situation is 
entirely different from that where the doctors agree 
to work on a unit system with dues fixed by an in- 
tervening agency over which the doctors have no 
control. Moreover, use of the unit system for sub- 
scribers permits the placing of a “ceiling” on the 
maximum cost of medical care per person ; the true 
insurance principle — definite rates and definite bene- 
fits — F preserved under this system. 

So far as possible, district administration will be 
put on an autonomous basis. In the discussion the 
Council suggests that discussion here should be cen- 
tered upon fundamentals and not upon details. In 
the deliberations of this body it will be impossible 
to work out or decide the many details in the in- 
auguration of a plan designed for state-wide cover- 
age eventually. The type of plan that the profes- 
sion desires, and its fundamental tenets, we respect- 
fully suggest should form the topics of your delib- 
erations. Details must be entrusted to representa- 
tives from various geographical areas and differing 
conditions of medical practice. 

Recommendation : The Council respectfully rec- 

ommends that this House of Delegataes, after due 
consideration and discussion, instruct The Council 
to take the necessary actions to create and put into 
operation an organization or organizations contain- 
ing the essential provisions embodied in the tentative 
drafts as presented by The Committee on Distribu- 
tion of Medical Care. 

Respectfully submitted, 

The Council, M.S.M.S. 
By P. R. Urmston, M.D. 

Chairman 

Attest : 

L. Fernald Foster, M.D. 

Secretary 

Dr. Urmston : Mr. Speaker, I now ask you to 
call upon the Chairman of the Committee on Dis- 
tribution of Medical Care to present these plans. 
Thank you. 

The Speaker: The Chairman’s address will be 
referred, to the Committee on Council Reports. 

The big moment has now arrived. Will Dr. Pino 
come forward? (Applause) 

Dr. Ralph H. Pino (Wayne County) : Mr. 

Speaker and Gentlemen of the House of Delegates : 
He shouldn’t have said what he said exactly because 
it makes the fall harder, if the fall comes. 

I want to read to you in its entirety the Report 
of the Committee on the Distribution of Medical 
Care before we take up any comments from the 
House of Delegates, in order that we may bring to 
you some of the thoughts that have accumulated 

February, 1939 


around the definite proposals that we shall make. 

It would be unnecessary, I believe, to do any 
more today than simply to accept one of three pro- 
posals, had you had the opportunity of sitting with 
us through many sessions in arriving at our con- 
clusions. Had that been possible, you would be able 
to see what we see when we stack up, so to speak, 
one thought against another. We have one definite 
opinion as to what should be done, and then some- 
one else brings up an opposing opinion and we get 
together in the middle of the road somewhere. I 
want to say to you that we have come together in 
the middle of the road as near as we believe it hu- 
manly possible to do in thinking of the interests pri- 
marily of the people, and then of the medical pro- 
fession and all groups concerned. 

Dr. Pino read the Report of the Committee on 
Distribution of Medical Care to The Council of the 
Michigan State Medical Society, during the reading 
of which he made interpolations. (Noted in smaller 
type.) 

REPORT OF THE COMMITTEE ON 
DISTRIBUTION OF MEDICAL 
CARE 

Group Hospitalization is insurance, but it is not 
a non-profit form of private insurance, rather it is 
a non-governmental form of public insurance. The 
voluntary movement of non-profit public insurance 
is in direct competition with the government, rather 
than with the private insurance carrier. To make 
certain the success, proper administration, and gen- 
eral availability of non-profit, voluntary hospital in- 
surance, a special enabling act covering this type of 
organization has been felt requisite by most of the 
states, and a number of such acts have been passed 
by state legislatures. 

Your Committee began its work on the assump- 
tion that both group hospitalization and group medi- 
cal care should be offered to the public as one serv- 
ice, in the best interests of the people. Therefore, 
your Committee developed 

1. A proposed Enabling Act, covering both hos- 
pital service and medical care (Exhibit A). 

One primary motive in thinking that through was this : 
You recall that we were told that any plan of hospital in- 
surance that should come forward must eliminate all med- 
ical services. In order, therefore, to provide the hospital 
insurance and the necessary medical insurance — that is, 
x-ray, laboratory and anesthesia — it would be necessary to 
set up alongside of the hospital insurance some medical 
insurance in order that we might compete with any group 
who would set up the other. Therefore, the necessity of 
an enabling act covering both hospital service and medical 
care. 

2. The proposed by-laws of the corporation, per- 
mitted under the Enabling Act, offering both hospi- 
tal service and medical care (Exhibit B). 

3. Articles of Incorporation (Exhibit C). 

In other words, we have gone through the setting up of 
practically all the necessary details leading up to that. I 
would suggest that you not try to look at that while we 
are going over this outline. 

Hospital insurance — a form of public service — 
must be made available to the largest part of the 
population. Therefore, the rate should be as low as 
is consistent with sound actuarial experience. 

In the contract with the subscriber, the rates and 
benefits, as studied by your committee, could be 
briefed as follows : 

Ward Plan ( Groups Only) 

Rates 

$ .60 a month, subscriber (employed). 

1.25 a month, subscriber and one or more de- 
pendents (wife, or husband and all unmar- 
ried children under 21 years, living at 
home). 


153 


SPECIAL SESSION— HOUSE OF DELEGATES 


1.00 registration fee per family. 

.60 for each additional adult dependent living 
with subscriber and totally dependent on 
subscriber for financial support. 

Semi-Private Plan (Groups Only) 

Rates 

$ .75 a month, subscriber (employed). 

1.50 a month, subscriber and spouse. 

1.75 a month, subscriber and dependent family, 
under 21 years, unmarried and living at 
home. 

1.00 registration fee per family. 

.75 for each additional adult dependent living 
with subscriber and totally dependent on sub- 
scriber for financial support. 

Let us not fall down over any detail of that kind. There 
is sufficient precedence upon which to go. We know what 
this will do by present experience. We know by the ex- 
perience here mentioned that it is possible to do more 
than is outlined in what is offered. We know that it 
creates a reserve. We know that we want that reserve 
created not for the purpose of increasing the cost of the 
hospital bed but of giving increased benefits to the patient. 
I think you can read through and around that statement. 

Benefits 

Maximum of 21 days’ care the first year ; 23 days 
the second year ; 25 the third year ; 27 the fourth 
year; 30 the fifth and subsequent years. 

The reason for increasing those days as the years go by 
is to offer a premium to the individual who remains in. 

Complete, beginning the first day. 

In other words, no waiting period. 

General nursing service. 

Operating and Delivery Rooms as often as neces- 
sary, ordinary medications, surgical dressings, or- 
dinary plaster casts. 

Meals and dietetic service. 

$3.00 (ward plan) or $4.00 (semi-private plan) a 
day towards purchase of private room (with con- 
sent of physician). 

Ambulance service in metropolitan area when or- 
dered by physician. 

$3.50 to $5.00 a day to out-of-state hospitals for 
emergency and accident care. 

Maternity coverage after ten months (the patient 
paying $2.00 per day towards each day’s care — to 
cover cost of two persons in hospital). 

Again let us not be disturbed about points of that kind. 
That can be entirely taken out of there if it seems the 
thing to do. It is put in as a buffer. 

Twenty-five per cent of all hospital costs for 120 
additional days. 

Age limit for new subscribers — 65 years. 

Anyone coming in at sixty-five, however, could continue 
to any age as long as the policy does not lapse. 

Rates to Hospitals 

$4.50 per day (ward plan) — subject to individual 
agreements with hospital. 

$6.00 per day (semi-private) — subject to individual 
agreements with hospital. 

Now you will notice a difference in the amount paid 
here. Here is $4.50 and $6, above $3.50 and $5, and there 
is a definite explanation for those things. Again those 
things can be adjusted. Let us not spend a great deal 
of time over that right now. It can be brought up by 
the Reference Committee if they so wish. There is a log- 
ical explanation for it and we would be glad to take it 
up with you. 

Your Committee on the Distribution of Medical 
Care developed in detail the proposed contract with 
the subscriber, based on the above essentials. 

154 


Within recent months, a number of lay-controlled 
corporations (other than insurance carriers) have 
been formed under the Insurance Code or the Cor- 
poration Code of the State of Michigan, to offer 
group hospitalization. These organizations have 
tended to stimulate a great public interest and desire 
for a group hospitalization plan sponsored by (a) 
the medical profession; (b) the hospitals; and (c) 
the public. To supply this ready market, certain 
hospital executives have within the last few weeks 
formed a group hospitalization corporation under 
the Corporation and Securities Commission — not the 
Insurance Department ; this plan was developed in- 
independently of the medical profession and of the 
public. Still believing that the best interests of the 
public would be served by a true non-profit, volun- 
tary organization sponsored jointly by the medical 
profession, the hospitals and the public, which had 
as its firm foundation an enabling act, representa- 
tives of the medical profession invited representa- 
tives of this recently-formed corporation to meet 
together on January 3, for the purpose of ironing 
out the major difficulty — certain diagnostic services 
— and meeting on a common ground. 

On every occasion and in every way, we have gone along 
in an attempt to work together with every group who have 
tried to do something along this line. The problem re- 
mained unsolved after a six-hour discussion at our last 
meeting with that group. 

One item of business taken up at this meeting 
was the “proposed model law to enable the forma- 
tion of non-profit hospital service associations un- 
der the supervision of the various state depart- 
ments of insurance” which was drafted by the Com- 
mittee on Hospital Service and Council on Hospital 
Care Insurance of the American Hospital Associa- 
tion. A copy of this proposed model law is present- 
ed to you today as . . . (Exhibit D). No provision 
for group medical care is included in this proposal. 

Now we were able to come to some conclusion with 
that group of hospitals who are setting up that particular 
plan as far as x-ray is concerned, and I have letters to the 
point that as far as the State Roentgenological Society is 
concerned they are satisfied with that arrangement. 

However, we have arrived at no conclusion as far as 
anesthesia and laboratory services are concerned. Where 
does that place us in the possibility of cooperating with that 
group of hospitals who are trying to set that up? Simply 
here, that we cannot go along with them until those other 
things are ironed out, according to the conclusion reached 
at the Annual Meeting of the State Society. And in order 
that it might not at some other point take up a good deal 
of time, it occurs to us that any organization setting up a 
type of hospital insurance should be formed through the 
Insurance Department rather than through some other 
department of the state set-up. 

On the matter of hospital insurance, there are three 
questions that we wish you to decide. 

Questions of the Committee 

1. Do you wish to instruct your Committee on 
Distribution of Medical Care to continue ef- 
forts with the Michigan Hospital Association 
and the representatives of labor, industry, ag- 
riculture, religious and educational organiza- 
tions, community councils, and other interested 
groups, in an attempt to obtain a non-profit 
group hospitalization plan sponsored jointly by 
the medical profession, the hospitals and the 
public? 

or 

2. Do you wish to instruct your Committee to de- 
velop a non-profit group hospitalization corpo- 
ration, owned and controlled by the State So- 
ciety, which indemnifies the patient in cash, 
and not in service benefits, said corporation to 
be a mutual or cooperative organization under 
the Insurance Code? 

or 

3. Do you wish to instruct your Committee to as- 

Jour. M.S.M.S. 


SPECIAL SESSION— HOUSE OF DELEGATES 


similate or affiliate with one or more of the 
lay-controlled group hospitalization corpora- 
tions (other than insurance carriers), which 
are already doing business? 

Now let us come back to Question No. 1. 

If you could have been at the various conferences with 
us and have heard the opposing opinions as to whether or 
not the Michigan State Medical Society should enter into 
the insurance business, or whether or not we should com- 
bine with others, you would have found it pretty much con- 
densed in the conclusion being that we should do what is 
emphasized in No. 1. 

In the first place, we have learned that the public feels 
that the practice of medicine is very much their business. 
It is an established psychological set-up in the minds of 
the American people within the last few years. It seems, 
therefore, an appropriate thing, particularly in these low- 
income groups, that we should unite with industry (cer- 
tainly they have stakes in it), that we should unite with 
labor, that we should unite with agriculture, that we should 
unite with educational interests, that we should unite with 
community chest interests, if we are going to be able to 
go to the legislature with an enabling act that will not be 
shot at as something that is purely from the medical pro- 
fession. 

But we say and we have maintained that these groups 
are getting medical care. I want to refer to one of these 
groups particularly and that is the Grange, representing 
agriculture. In meeting with one of the most influential 
members of the Grange, not alone in Michigan but in the 
United States, a few days ago, I said, “But remember this, 
there is no country where medical care is so nearly ade- 
quate as in the United States.” 

This individual, whose influence compares favorably with 
the influence of any doctor in the United States, said to 
me, “You do not know what the condition of medical care 
is among the farmers of the United States, when you con- 
sider the cost as compared with what the cost used to be.” 
Making a personal reference, this individual said, “When 
you lived on a farm” (and I was discussing this from 
experience) “there were not transfusions, there were not 
pneumonia typings to be done.” I was surprised at the 
extent of knowledge that these people have of what is re- 
quired in medical care. He went into the question of milk 
production, where they have to be so careful now in see- 
ing to it that they do not have undulant fever. “Here 
are these things and if we do not have some way where- 
by we can put $2 a month of $3 or whatever it is in 
to pay for them, we are going to the United States Gov- 
ernment and are going to ask that it be gotten otherwise.” 

I want to tell you that the sympathetic attitute of that 
individual was not antagonistic at all. They just had this to 
say, “All right, we understand your problems, but we must 
have it.” 

That brings us to this : Shall we not go to agriculture 

and to labor and to industry and say, “Come on with us. 
Let us do this thing together?” If at this time we do that, 
there is very great likelihood that they will leave the man- 
agement of it to us. We find there is very great interest 
on the part of important industrialists and others to want 
to come in with us to guide us from their angle and to let 
us do this as we think it ought to be done. 

“No. 2. Do you wish to instruct your Committee to de- 
velop a non-profit group hospitalization corporation, owned 
and controlled by the State Society?” There is a possi- 
bility, but on that day when the House of Delegates of 
this Society instructs this Society to do that independently 
and on their own, the President of the Michigan State 
Medical Society becomes the president of an insurance 
company and he has great loads on his shoulders at the 
present time in relationship to medical care in the State 
of Michigan. On that day the Executive Committee of 
your Council becomes the Board of Directors, so to speak, 
of an insurance company. 

We still believe it can be done if it is necessary, but is 
it necessary for us to assume that when these others want 
to come in and help? If we do it ourselves, believe me, 
gentlemen, they will be sitting back and saying, “Let’s see 
what they can do. Let’s see how it comes out.” 

“No. 3. Do you wish to instruct your Committee to 
assimilate or affiliate with one or more of the lay-controlled 
group hospitalization corporations other than insurance car- 
riers, which are already doing business?” 

I want to add in there not alone “other than insurance 
carriers” because the problem comes up that the insurance 
carriers are the companies such as the Metropolitan, Pru- 
dential, and the larger insurance companies. Those who 
are not insurance carriers are such concerns as come up 
from time to time and try to write this kind of insurance. 

We have those in the group constituting the Committee 
on the Distribution of Medical Care who were definitely 
imbued with the fact that we should turn this matter en- 
tirely over to the insurance companies, and very honestly, 
men who have made a deep study of it. One of these men 
we had appointed to the Committee because of that knowl- 
edge. The Executive Committee asked us to appoint a 
subcommittee to look into the possibilities of doing just 
that thing. I am trying to give you the argument. 

Wouldn’t it seem logical to say here. We want to prac- 
tice medicine. We don’t want the insurance companies to 

February, 1939 


practice medicine. Therefore, they don’t want us to go 
into the insurance business. That seemed very logical in- 
deed. 

So this subcommittee had many conferences with men 
who represented not alone the individual insurance com- 
pany but those who represented the association to which 
these companies belonged. This subcommittee was a strong 
committee. I was very much surprised when the report 
came in : It can’t be done. 

Now, if you would like to go into the discussions of 
why it can’t be done and want to take three hours for it 
right now, we will do so and go into many statistical de- 
tails. We will not do that, but it can be done. We can 
relinquish our interest, so to speak. We can even go to 
the board of directors of some of these companies and turn 
it over to them. Some of the regular insurance carriers, 
those who write not only sickness and accident but health 
insurance, tell us that they don’t know that they want to 
do it in this group under any circumstances. There are 
those companies who today are just waiting for us to 
support their plan and to come in with them to a certain 
extent. 

Our conclusions are these, as has been the thought of 
the medical profession from the time we first heard the 
matter of socialization of medicine discussed, that on that 
day, when there is any form of socialization of medicine 
there will be those commercial interests, whether it be the 
selling of bed pans or the selling of insurance for a profit. 
Labor and agriculture are saying, “We want to enter into 
a non-profit thing.” 

Mr. Martell, at the meeting in Lansing some time ago, 
got up and made this statement, “We find it to be the 
opinion of labor that they do not propose to enter into 
any plan that gives to the profit insurance carrier 30 per 
cent or more of the profit, taking it out of the medical 
care that they feel is due them.” When it comes to deal- 
ing with this low income group, where the medical pro- 
fession sacrifices in its fees and others are sacrificing all 
along the line, I want to say to you that Mr. Martell was 
right in that regard. That is my personal opinion. 

Group Medical Care 

The utilization of the group principle in the wider 
distribution of quality medical care in America has 
not been sufficiently general or broad to present 
much actuarial data or accurate experience tables. 

That has been a thought in the minds of many members 
of the medical profession and, therefore, has created fear. 
Now let me read you the next statement. 

Nevertheless, private insurance companies are set- 
ting up this type of coverage this year in 55 new 
policies. 

They do not fear it. 

In our own state, the State Society’s Committee on 
Medical Economics made an exhaustive survey and 
presented some interesting data and statistics to 
the M.S.M.S. House of Delegates in 1934. The 
Committee’s estimates for annual cost and expend- 
iture figures on the services of physicians actually 
purchased were : 

(a) General practitioner of medi- 

cine $ S.00 per person 

(b) Report of Annual Physical 

Examination SO per person 

(c) Report of Immunization... .25 per person 

(d) Medical Specialists’ Services 3.00 per person 

(e) Laboratory Services 1.00 per person 


Total $ 9.75 per person 

(f) Administration, 10% 98 per person 

(g) Surplus, 5% 49 per person 


Grand Total $11.22 per person per annum 


And again let us not stumble over detail in this partic- 
ular regard. It is subject to expansion or contraction. 

Whatever may have become of that report, which cost 
much and is very valuable, these figures can be depended 
upon. 

Please note the above includes only the figures for 
that portion of medical care which can be done by a 
doctor of medicine exclusively and unaided, in pri- 
vate practice, with some few exceptions. 

Based on the above figures, which represent ex- 
penditures for services actually purchased — not for 
all the services desired, a high percentage of physi- 
cians’ services now being purchased could be under- 


155 


SPECIAL SESSION— HOUSE OF DELEGATES 


written under the insurance principle at approximate- 
ly $1.00 per month per subscriber in any group med- 
ical care plan. However, this $1.00 per month sub- 
scription might not be an adequate premium to cov- 
er all the medical services needed and procurable 
from the physician. Thus the same standard ob- 
jection could be raised: That for a very definite 

and limited premium, a very indefinite and unlimited 
amount of service is promised by the physician. 
This is a travesty on the insurance principle. 

In life insurance they charge a certain premium. They 
know that you are going to die and the amount of money 
that will be paid out can be estimated. But if you pay 
a certain premium for sickness insurance and then have 
the sky the limit it just can’t work and, therefore, should 
not be called insurance, and that is the reason for that 
statement. We can go into further detail if you like. 

If the total of medical cost per person is set at a 
maximum limit, and if a limitation is made whereby 
the individual assumes the cost of the initial and 
minor charges of the illness, the very modest rate 
of $1.00 per employed subscriber might be set, which 
would adequately cover the catastrophic occurrences 
of illness in the borderline and low-income groups 
especially (up to incomes of $1,500.00). 

Again let us not fall over that $1,500. Remember the 
interests in Washington, we understand, would like to 
double that. 

To accomplish this, benefits could be placed on 
either one of two bases : 

1. The “unit system,” whereby an employed sub- 
scriber would be entitled to a maximum block 
of units (not dollars) of medical service, as 
for example : 


50 calls of a physician 300 units 

1 major operation 300 units 

1 minor operation 100 units 

1 fracture 150 units 

Miscellaneous diagnostic service 150 units 


Total 1,000 units 


Someone said, “That is like buying so many poker chips.” 
I don’t know anything about that, but someone could ex- 
plain. (Laughter.) 

All types of medical and surgical care and diag- 
nostic service, performed by the doctor of medicine 
in private practice could be offered, with some ex- 
ceptions. The patient may elect to utilize all his 
units in house or other calls, or for sqveral opera- 
tions, or for diagnostic procedures. 

You see there would be a limit. 

A larger block of units could be purchased by the 
subscriber at slightly higher premiums, in propor- 
tion to increased benefits. 

But again there would be a limit. 

The patient would assume the cost of minor 
charges, for the first 10 or 15 units (one call per 
day for 3 or 5 days). 

You see, this puts a limit of the floor of it also. This 
individual representing the Grange said to me, “We can get 
along somehow. The doctors are good to us. They come, 
and if we can’t pay them now we can pay them some other 
time, but the people are just panicky when it comes to 
something that is going to cost them $150 or $300 or $400, 
and they want their children to have what is good the 
same as you and I.” 

No. 1, which we have read, has to do with the unit sys- 
tem, and No. 2 has to do with the time system. 

or 

2. The “time system” whereby an employed 
subscriber would be entitled to a maximum number 
of days’ or weeks’ coverage of medical care, as for 
■example, 26 weeks. Again, all types of service per- 

156 


formed by a doctor of medicine in private practice 
could be offered, with some exceptions. However, 
under this system the patient with the neurotic 
trend would have no particular inducement, during 
the 26 weeks of coverage, to conserve his or her 
medical resources. 

The patient would assume the cost of minor 
charges for the first three (or five) days of medical 
care. 

Under either of the above two plans, the true 
insurance principle of definite rates and definite ben- 
efits would be preserved. 

Fee schedules to reimburse the physician would 
be developed on a unit basis, with certain medical 
services designated as representing a certain number 
of units. (For portion of such a fee schedule, see 
Exhibit E). At the conclusion of each month, a de- 
termination would be made from the financial fig- 
ures of the plan to ascertain the unit value (as for 
example, if $50,000 were collected over and above 
operating costs, and the total number of units of 
service for the month was 50,000, the unit value 
would be $1.00). Compensation for the physicians’ 
service would be determined by the number of 
units due him based on the unit value, on which a 
maximum would be set, to build up the reserve. A 
financial reserve necessary to start the plan could 
be created by cooperating physicians relinquishing 
their rights to the first amounts due them up to a 
designated amount (which might be $50 or $100) 
until a proper reserve had been created, when said 
money would be paid back to the physician, with or 
without interest. 

Let us not stumble over that at all. Any of us going 
into a thing of this kind would be willing, if by that means 
it would help to get under way, to do it. 

The plan should be open to ever}' licensed doc- 
tor of medicine who agrees to abide by the rules 
and regulations. This will eliminate any charge of 
contract practice. The patient would have free 
choice of physician, M.D. 

The Committee sees no reason why the plan could 
not be extended to include the care of indigent or 
semi-indigent groups by contractual arrangements 
with the community. 

That is a big subject in itself. It is potent with good 
things. 

The subscriber’s contract would provide that the 
plan is not to render medical care or furnish him 
with a physician, but that it merely accepts the re- 
sponsibility of paying for the cost of medical care 
and discharging the obligation of the subscriber 
with the attending physician, provided he is a co- 
operating doctor. 

How much like the practice of medicine as it has always 
been ! How different from what it would be if there were 
opportunity for the doctor, through some political force, to 
get into this position or that. If you want to look this 
over and read the paragraph of definite importance to us, 
mark that paragraph and read it again later. 

The physicians who participate in the plan would 
be asked to agree to arbitration of any questions 
in dispute and to abide by the decisions of the 
Board of Control with reference to any questions 
which might affect their continued membership and 
service to subscribers, realizing that the successful 
operation of any such plan is contingent upon the 
proper cooperation, deportment and consideration of 
the doctors of medicine who are rendering profes- 
sional service to the subscribers. 

We have learned this, that there is a power to the polic- 
ing of these things by the medical profession. If you are 
in Detroit some day and have three or four hours in which 
you would like to study that principle, we can send you to 
one branch of our Probate Court and you can see what 


Jour. M.S.M.S. 


SPECIAL SESSION— HOUSE OF DELEGATES 


happens to medical costs when the matter of whether or 
not this or that should be done is left in the hands of the 
county society. 

Your Committee believes that a group medical 
care experiment, based on the above general princi- 
ples, could be started and tried in certain areas or 
communities where the county medical society will 
act as guarantor of service, and that a nonprofit cor- 
poration, permitting state-wide service and care by 
eventual development, should be formed. 

We can only arrive at the conclusion after these studies 
that it ought to be formed, that the people in any town up 
through the state or any group of agriculturists should have 
the right to put their money into a pot from which the 
cost of their medical care might come, provided it can be 
regulated, and it can be, by the medical profession. 

We must give opportunity to experimentation, to 
keep us free from governmental encroachments. 
Without a constructive program, we might be easy 
prey for commercial or political influences, 

Two special delivery letters and one telegram came dur- 
ing the night last night to that point. They want to get 
their hands into it. When commercial interests and politi- 
cal interests both want to get their hands into it, if we let 
them do it, make up your minds that the medical hands 
will be tied and the patient will suffer. 

not in the best interests of the public. If we go 
ahead with some forward movement at this time, 
and give it wide publicity, 

Why wide publicity? There comes a time when we can- 
not be so modest as a whole medical profession. 

the profession will be in a strong position to direct 
public opinion, and thereby influence good legislative 
action in the interest of public welfare. 

Understand they are not recommendations. They are 
questions. 

Questions of the Committee 

1. Do you wish to instruct your Committee on Dis- 
tribution of Medical Care to form a non-profit 
group medical care corporation in this state, 
to permit experiments with group medical care 
in various areas of Michigan with the co- 
operation of labor, industry, agriculture, re- 
ligious and educational organizations, commu- 
nity councils, and other interested groups? 

2. If so, shall the experiment be on the “unit sys- 
tem” for subscribers and physicians? 

or 

3. If so, shall the experiment be on the “time sys- 
tem” for subscribers and the unit system for 
physicians ? 

(Applause.) 

The Speaker: Our afternoon session will be 

held in the Ivory Room. We have about forty-five 
minutes. While Dr. Pino has rendered a wonderful 
report and gone into great detail, I think it is only 
fair to let the members ask any questions about 
any points on which they are in doubt or discuss 
this report now before it goes to the Reference 
Committee. 

Dr. J. M. Robb (Wayne County) : I should like 

to ask a question. There seems to be some doubt 
as to whether an enabling act should be passed. I 
would like to have a discussion among those who 
feel that it should and those who feel that it should 
not, because in the handling of this problem that is 
the first thing to be considered, and the only way 
that we are going to make progress is by acting 
in a very definite way. 

I have talked to some people who feel it is im- 
possible for either of these services to be granted 
to the people of the State of Michigan without an 
enabling act. I have talked to others who feel that 

February, 1939 


it is not necessary. I should like to get this matter 
as promptly before this House of Delegates as we 
can. Upon that basis only can we possibly vote. 

The Speaker: Maybe it would be a good idea 

to have Dr. Pino answer your question, Dr. Robb, 
if someone familiar with what an enabling act is 
and how it could be passed would explain that, 
either Dr. Gruber or Dr. Christian. 

Dr. Pino: May I suggest Dr. Gruber? I believe 
he has gone into it very thoroughly. I believe 
Dr. Insley feels we might do better without it under 
some circumstances. If those two could be called 
on — and Mr. Burns has been discussing it a great 
deal — it might be amplified. 

The Speaker: Dr. Gruber, would you come for- 

ward ? 

Dr. Gruber : I am not quite ready. 

The Speaker: Mr. Burns, can you give us a lit- 

tle enlightenment on an enabling act? 

Mr. William J. Burns (Executive Secretary) : 
Mr. Speaker and Gentlemen : It is the recommen- 

dation of the American Hospital Association to all 
who are considering group hospitalization that a 
very firm foundation be put under such a plan, and 
it recommends an enabling act. 

At the present time in Michigan there is no possi- 
bility of creating a group hospitalization plan which 
is strictly not an insurance company. There are 
four types of insurance companies which are under 
the control of the insurance commissioner. 

First, there is the stock company selling insur- 
ance. You know the typical stock company, such 
as Metropolitan Life. There is the mutual insur- 
ance company, and you all know just what that 
means. Rather large reserves must be set up with 
the treasurer, such as $200,000, to insure promised 
performance on the part of the corporation to the 
subscribers. So the state steps in and protects the 
policyholders by insisting that these corporations 
set up rather large reserves and sums of money or 
bonds wdth the Treasurer of the State of Michigan. 

The third type under the Insurance Commissioner 
is called the cooperative. The cooperative doesn’t 
require such tremendous reserves. I think only 
about $5,000 is required and other considerations. 
I understand in Michigan there are two corpora- 
tions under the cooperative section of the insurance 
code which now are selling group hospitalization. 

Finally the reciprocal, which does not apply to 
group hospitalization. 

There is a possibility also of having a corporation 
for the purpose of selling group hospitalization 
under the Security and Corporation Code, not the 
Insurance Code. That is the type of corporation 
under which the plan developed by certain of the 
hospital superintendents of Detroit is working, until 
such time as an enabling act has been placed on the 
statutes. 

Two employes of the Insurance Department have 
stated that for the success of any plan and for the 
protection of the subscribers, it is their opinion that 
a group hospitalization corporation should be de- 
veloped on the foundation of an enabling act. That 
enabling act will allow such a corporation to be 
formed. It will still have the control of the In- 
surance Department. The Insurance Commissioner 
will have charge of approving the forms and all 
those other details, but the corporation (nonprofit) 
will be exempt from tremendous reserves. In other 
words, it won’t be necessary to put up, let us say, 
$200,000, and it is hoped that the legislature will 
also exempt it from taxation, since it is a public 
service organization in the true sense of the word 
rather than an insurance company. In other words, 
it is a public insurance proposition rather than a 
private insurance company, as Dr. Pino has brought 
out. 


157 


SPECIAL SESSION— HOUSE OF DELEGATES 


An enabling act is introduced as a bill in the 
Legislature which after going through one House, 
is passed by the second, then is signed by the Gov- 
ernor, and thus becomes a law which permits the 
creation of group hospital corporations to perform 
certain acts and have certain privileges but which at 
all times is under the supervision of the Insurance 
Department in the interest of the subscribers. 

The Speaker: Dr. Gruber. 

Dr. T. K. Gruber (Wayne County) : Mr. Speak- 
er and Members of the House of Delegates : The 

question has been brought up as to whether it is 
necessary to have an enabling act. One of the first 
answers is that the experience throughout the coun- 
try, so far as group hospitalization is concerned, 
has been that an enabling act is necessary. 

With group hospital insurance you are not indem- 
nifying people in cash ; you are indemnifying them 
in service. You have a cooperative organization 
made up of hospitals, the public, the medical pro- 
fession, and the like, who are acting as agents for 
the hospitals and for the patients in rendering them 
service, and for that it seems to be necessary to 
have a different law enacted than is in existence 
at present because all of the insurance laws at 
present provide for the indemnity to be paid, to 
the individual who pays the subscription, in cash. 

There are certain other arrangements in the mat- 
ter of group hospitalization as it is practiced in this 
country which allow a rather loose organization, 
whereby certain things can be done that are not 
done in insurance, in the matter of building up re- 
serves and of carrying these reserves and not dis- 
tributing the reserves, and at the present time there 
is nothing on the statute books of Michigan that 
makes it possible to do that. 

The organization that has been formed, as stated, 
is under a different arrangement. It may be on a 
legal shoestring. At least that is the idea of a lot 
of individuals who have studied the plan. If an 
enabling act is passed it makes it legally possible 
to go into this thing without fear of attack. 

Now, when it comes to the question of an en- 
abling act for so-called group health insurance, as 
to just what sort of an enabling act will be neces- 
sary for group health insurance, it seems to me that 
it would mean no different relationship between the 
individual and the doctor than there is in the group 
hospital insurance between the individual and the 
hospital. 

It is true that a corporation can be formed by 
putting up the necessary cash or the necessary 
securities, the same as any other insurance organi- 
zation. I don’t know what the minimum amount is 
that is necessary. It would run probably $15,000. 
On that basis you can form a regular insurance com- 
pany, a non-profit insurance company, under the 
present laws. But there are some fifty organiza- 
tions operating today under the revised insurance 
laws, and the interpretation seems to be that you 
cannot indemnify people for service under the pres- 
ent insurance law. 

I believe that is the explanation of the situation. 

The Speaker: Dr. Insley, can you tell us why 

we should not pass an enabling act? Have you any 
ideas on that subject? 

Dr. S. W. Insley (Wayne County) : Are you 

speaking of group hospitalization or sickness or 
both? 

The Speaker: Both. Dr. Gruber just explained 

why an enabling act was necessary. 

Dr. Insley: As I understand it, all of the serv- 

ices or indemnities which might be offered by a 
company working under an enabling act can today 
be offered by companies operating under the Insur- 
ance Commission and upon a mutual basis. 

158 


It seems that there is a distinction made in that 
individuals or groups who might have $5 or $50 
or $500 and want to go into this business (we will 
call it that) would have to go in under a new law, 
an enabling act. A corporation trying to do this 
requires an enabling act where they are putting in 
their own money. A group of people, on the other 
hand, can band together in a mutual system of bene- 
fits to themselves and do it under our present laws 
today and be governed through the Insurance Com- 
mission. 

As one last remark on this, an enabling act of 
any type, whether group hospitalization or sickness 
insurance, cannot be made into a monopoly, so that 
such business can be done by doctors only. Any 
enabling act allowing a corporation to do this busi- 
ness would also allow 2,500 other corporations to 
go into the same business if they had the money. 
You cannot make an enabling act that will give 
doctors or the Michigan State Medical Society ex- 
clusive right to sell either group hospitalization or 
medical service. 

Dr. Gruber : Mr. Speaker and Members of the 

House : There is a pamphlet put out by the Ameri- 
can Medical Association, and I believe edited by 
Dr. Leland, on “Group Hospitalization.” If each 
one of you would get a copy of this and read it 
you would find the best dissertation on group hos- 
pitalization that has ever been put out. He goes 
into all the faults and all the virtues and all the 
vices. 

On Page 223 of this pamphlet it reads : 

“The procedure that is now being followed is to secure 
the passage of a special enabling act which exempts hos- 
pital service corporations from the deposit requirement of 
the insurance laws but at the same time gives the insurance 
commissioner certain supervisory powers over these cor- 
porations. 

“The change in the legal relation of group hospitalization 
plans has served to make it difficult to promote commer- 
cial plans. The enabling laws focused attention on several 
important requirements: The majority of the directors of 

a hospital service plan were required to be directors or trus- 
tees of the hospitals which had contracted or might con- 
tract to render the hospital service; some method of ap- 
proval of the participating hospitals was also required; the 
certificate of incorporation had to be endorsed by the com- 
missioner of insurance or the department of social welfare; 
the proposed contract rates, acquisition costs and methods 
of operation were subjected to the approval of the commis- 
sioner of insurance; annual reports had to be filed, and 
the records and affairs were open to inspection by exam- 
iners from the insurance department; and the investment 
of funds was restricted to those investments permitted life 
insurance companies. 

“These provisions constitute a notable step forward in 
the supervision of hospital service plans.” 

Then he goes on in a couple of pages on the 
shortcomings. 

“Despite these shortcomings, the resulting closer supervi- 
sion of hospital service corporations has forced the pro- 
moters of commercial plans, as well as those who desire 
to offer a more extensive contract, to form a new institu- 
tion — the hospital insurance company. The necessity to 

organize a nonprofit corporation, with hospital administrators 
and physicians controlling the policies, was too much of a 
deterrent for profit-taking and overzealous promoters. Fur- 
thermore, hospital insurance companies could be readily 
formed in states in which enabling acts would have to be 
passed to permit the operation of hospital service plans. 
The mutual assessment insurance laws provided a direct 
method of organizing such companies. The requirements 
usually were that a company had to have a few hundred 
applicants, several thousand dollars as ‘legal’ reserve and 
a certain reserve for unearned premiums. Even where an 
enabling law was on the statute books of one state, a group 
hospitalization plan, in operation for four years before the 
passage of the law, and a newly organized plan each elected 
to qualify as a mutual assessment insurance company by 
depositing $25,000 with the insurance commissioner rather 
than to organize under the enabling law. The enabling 
law contained a definition of hospital service which was 
interpreted to exclude the services of radiologists and 
anesthetists. The possible competition of law organizations 
and insurance companies selling a more complete hospital 
insurance policy under the mutual insurance laws was the 

Tour. M.S.M.S. 


SPECIAL SESSION— HOUSE OF DELEGATES 


compelling factor which caused the organization of these 
plans as hospital insurance companies.” 

I just wanted to read that excerpt from Dr. Le- 
land’s dissertation. If you write to the American 
Medical Association you can get that volume. It 
is hard reading, but when you get through you will 
know something about group hospital insurance. 

The Speaker: Is there any further discussion 

on this problem? 

Are you satisfied, Dr. Robb? 

Dr. Robb: Air. Chairman and Gentlemen: I am 

entirely satisfied so long as the delegates understand 
the implication, because upon no other basis can you 
possibly vote when the time comes. If you under- 
stand it, that is the only reason for my calling it to 
the attention of the group. 

Dr. R. M. AIcKean (Wayne County) : I wonder 

whether an opinion could be obtained from the At- 
torney General’s Office as to whether or not an 
enabling act is necessary under such circumstances. 

The Speaker : I don’t think any opinion has been 

secured. 

Maybe we could put that question to Attorney 
Hazen J. Payette during the recess and have him 
look it up. 

Dr. S. W. Insley (Wayne County) : I can an- 

swer that at least partially, Dr. McKean, by say- 
ing that the Insurance Commission at the present 
time is licensing mutual outfits on group hospital- 
ization. It is permissible under the state law upon a 
mutual basis. 

Dr. R. L. Novy (Wayne County) : Have we any 

legal advice on that as to whether or not it is de- 
sirable? Why should we discuss this problem? 
It is a question of a legal problem, it seems to 
me, and a question of legal expediency as to 
where you are going to go, not a question of 
decision here. 

Dr. Pino: Dr. Novy is correct. Let us just 

say this in dismissing that, if the time has come 
to dismiss it, that if we need an enabling act 
we can get it, if we have these other organizations 
interested in going along and helping us to do 
it. If we step out by ourselves and try to do 
it, we will have difficulty. 

As to the statement that if there is an enabling 
act any group can act under it, no group can act 
under an enabling act if it doesn’t have public 
support. If we have the interested groups, we 
will have public support. 

In relation to that fact also, any individual can 
be armed to go deer hunting if it is legal. It 
can be abused all along the line. 

I don’t believe we need to worry about the matter 
of the enabling act now, providing we have the 
cooperation of all the various groups. 

I am speaking of this from the standpoint of 
the practical political side. 

Dr. R. C. Perkins (Bay-Arenac-Iosco-Gladwin) : 
The question came to me, after glancing over this 
proposed enabling act, as to the authorship of the 
enabling act. That the Committee probably can 
tell us. I am not an attorney. If there ever was 
an act that created an absolute monopoly, this 
is it. The A.M.A. is accused of being a monopoly, 
and we are all a part of the A.M.A. As I read 
this thing, it certainly means a monopoly to say 
that any number of persons can form a corpora- 
tion to go ahead and start up some such proposi- 
tion as this. It also says that nothing in this 
act shall be construed so as to permit a hospital 
or other corporation to engage in the practice 
of medicine in violation of Act 237 of 1899 as 
amended or to contract to furnish the service of 
a physician for members. 

I-'ebruary, 1939 


No other organization can go ahead. They 
can form an organization, but they cannot con- 
tract to furnish the services of a physician for 
their members. 

I was wondering about this. To my mind it 
creates a monopoly. If it does create a monopoly 
under those conditions certainly it would be fought 
by every insurance company and by every practi- 
tioner of any type in the State of Michigan. 

Dr. Pino: You are referring to Exhibit A, 

are you not? 

Dr. Perkins : Yes. 

Dr. Pino : Exhibit A was set up as the first 
thought relative to creating a bill whereby we 
could practice both hospital insurance and medical 
insurance, was it not? 

Now, you don’t expect us to bring to you a 
bill stating that everybody can do these things. 
If you would go through this you would find so 
many things that you could conscientiously attack 
that it would bring to your attention the very 
thing that came to our attention last week when 
we spent many hours with Mr. C. Rufus Rorem 
and with the hospital people in trying to arrive 

at something that would be mutually agreeable. 
In this we were trying to set up something to 
which we could both agree to a certain extent, 
knowing it would have to be modified. 

The Speaker: Is there anyone else who has 

any questions he would like to ask? 

If not, we will refer this report to the Reference 
Committee, headed by Dr. Insley. You can see 
the names on the board. They will meet in the 
Ivory Room during the recess. 

We have a few more minutes, and there is 
another matter we might take up now. That is a 
letter of support to Dr. Olin West and the A.AI.A. 
in their hour of trouble. Dr. Luce, would you 
care to talk about that now? 

RESOLUTION OF SUPPORT TO A.M.A. 

President Luce: Air. Speaker and Alembers of 

the House of Delegates : Those who heard my 

remarks this morning have a thought that will 

lead you to the purpose for which Dr. Riley has 

just made this statement. I am not a member 
of the House of Delegates, but with your per- 
mission I would like to recommend to you that 
you take some official action as the House of 
Delegates of Alichigan State Medical Society in 
which you pledge the support of the medical 
profession of the State of Michigan, not alone to 
the officials of the Association but to the organiza- 
tion as a whole, because I hope you felt this 
morning that this attack on your integrity, this 
attack on your motivation, has been made upon 
you directly as well as those named in the indict- 
ment. 

I feel that it would be a consolation and sup- 
port to the national organization should you by 
some official act express to that organization your 
willingness to cooperate, your belief in its integrity, 
and your willingness to fight and carry the issue 
to the people of this country on the basis of its 
merits. (Applause) 

The Speaker: At the Council meeting last 

evening a similar resolution was passed. 

Dr. Insley : As Dr. Robb pointed out a few 

minutes ago, there are so many questions arising 
that we would all like to have our minds clarified 
a bit. I hope everybody comes into the Reference 
Committee meeting this afternoon and helps the 
Committee out. 

To answer a question brought up just a minute 
ago on this corporate practice, under the enabling 
act, we already have a monopoly as far as the 
practice of medicine is concerned. We doctors 

159 


SPECIAL SESSION— HOUSE OF DELEGATES 


are practicing medicine and nobody else is prac- 
ticing. This act will not change that a bit. My 
argument is, however, that it still allows other 
corporations to engage in sickness insurance with 
no guarantee as to what the payment to physicians 
might be. They might decide that office calls 
could be paid for at the rate of 25c or 50c or 
$1, or operations at 50 per cent fees, all the way 
down the line. A government unit, such as the 
H'OLC, could incorporate and decide, after getting 
150,000 or 200,000 members, to pay for office calls 
at any rate they choose. 

Does that explain the difference? 

AUTHORIZATION TO THE COUNCIL 
RE FINANCES 

President Luce: I am sorry to take so much 

of your time, but it would seem desirable to me 
that this House of Delegates authorize the Execu- 
tive Committee of the State Society to make such 
expenditures of money, either from the funds of 
the Society or, if necessary, from contributions 
or assessments on the members of the organization 
to defray such expenses as in the judgment of 
the Executive Committee might be necessary under 
existing circumstances for the ensuing year. 

The Speaker: Are we to infer, Dr. Luce, that 

you mean as far as the A.M.A. is concerned, 
to offer financial assistance to it? 

President Luce: By any method or procedure 

that the judgment of the Executive Committee 
and the officers of the Society might decide was 
necessary. 

The Speaker: I raise a point of order. Has 

not the Executive Committee that right now to 
appropriate money as it deems necessary? 

President Luce : I believe it has. On the 

other hand, I was asking even more than that. 
I was asking that the Executive Committee be 
authorized to spread an assessment on the Society, 
if in its judgment they saw it was necessary. 

Dr. P. L. Ledwidge (Wayne County) : Allowing 

for my natural dumbness, I would like to know 
just what Dr. Luce means. Is he willing to say 
what we want money for so we will know what 
we are doing? 

President Luce spoke off the record. 

Dr. Urmston spoke off the record. 

The Speaker : I will appoint a committee to 

bring in a resolution this afternoon covering pro- 
posed resolutions to the A.M.A. , that committee 
to be composed of 

W. R. Torgerson (Kent), Chairman 
Andrew P. Biddle (Wayne) 

J. M. Robb (Wayne) 

Dr. Robb spoke off the record. 

Dr. Henry Cook : As Chairman of the Contact 

Committee to Governmental Agencies and associate 
of the Legislative and Public Relations Committees, 
I would like to state there are many problems 
which we do not now know. Dr. Robb has men- 
tioned that the American Medical Association is 
under attack by the Treasury Department. Equally 
so has an assessment been placed against your 
State Society for a certain period, and that time 
may be extended to ten years. 

In the work of your Committee in contacting 
various individuals and legislators, both state and 
national, the time of certain members of your 
profession is required to carry on the work. There 
are certain expenses thereto incurred. They may 
be legal expenses. They may be the payment 
of the travelling expenses of those individuals. 
There is no way today of telling just to what 
extent that will go. It may be that the budget 
is ample, but legislatively in the past our funds 

160 


were much depleted. I believe this matter should 
be referred to a committee that Dr. Luce has 
brought up. I believe what I am stating is the 
thing he had in mind. 

I think a committee should report back to you 
this afternoon some recommendation giving or not 
giving, whichever you may deem advisable, the 
Executive Committee or the Council, authority to 
take such action as to finance legitimate business of 
the profession of the State and the Society. I 
can assure you that it will be properly handled, 
without any question. (Applause) 

The Speaker: It seems there are two items 

of business we have been talking about during the 
remarks of the last few speakers. A committee 
was appointed to draft suitable resolutions to send 
to the A.M.A. I am going to appoint another 
committee to bring in a resolution on this finance 
proposition. On that committee I will name 
H. W. Wiley (Ingham), Chairman 
R. C. Perkins (Bay) 

R. M. McKean (Wayne) 

I want Dr. Carstens, the Chairman of the 
Finance Committee, to sit in with them when they 
draft these resolutions. 

It is now one o’clock and we have to vacate 
this room. 

Dr. Insley, can you tell me how long it will take 
your committee, to get some lunch and report 
back? 

Dr. Insley : I think that plenty of time should 

be used in discussion before the Reference Com- 
mittee. On the other hand, I feel a certain time 
limit should be placed on such a hearing. I would 
suggest an outside limit of two hours, including 
lunch. 

The Speaker: The Chair will then entertain a 

motion to recess until three o’clock. 

President Luce : Before you put that motion, 

may I make this suggestion? It saves a lot of 
time on the floor of this House if individual 
members who have these problems will take them 
up directly with Dr. Insley’s committee where 
it can be threshed out. 

Dr. P. L. Ledwidge (Wayne County) : I move 

we recess until three o’clock. 

Dr. Pino: I would like to suggest, as a practical 
thing, that while that committee is in session they 
take their places at the table at the front of that 
room and discuss this thing and let everybody who 
will sit in that room, as you would in a panel 
discussion. A good many things will be brought 
out, and you will know what it is about without 
having to depend on their word alone. 

The Speaker: There has been a motion made 

that we recess until three o’clock. Is there a 
second? 

The motion was seconded by Dr. McKean of 
W r ayne County, put to a vote and carried, and 
the meeting recessed at one o’clock. 

SUNDAY AFTERNOON SESSION 

January 8 , 1939 

The meeting was called to order at three-fifty 
o’clock, Dr. Riley, the Speaker, presiding. 

The Speaker: The second session of this meet- 

ing will now come to order. 

Has the Credentials Committee its report? 

Dr. Ledwidge: Mr. Speaker, we have sixty-five. 

Dr. G. H. South wick (Kent County) : I move 

that sixty-five constitute the roll call for the second 
session of the House of Delegates. 

The motion was seconded by Dr. McKean of 
W^ayne County and carried. 


Tour. M.S.M.S. 


SPECIAL SESSION— HOUSE OF DELEGATES 


The Speaker: The first thing we will take 

up is a report from Dr. Torgerson. 

REFERENCE COMMITTEE REPORTS 
ON RESOLUTIONS 

Resolution of Support to A.M.A. 

Dr. W. R. Torgerson (Kent County) : Mr. 

Speaker, the Committee made up of Dr. Biddle, 
Dr. Robb and myself met and formulated the 
following resolution : 

“The House of Delegates of the Michigan State Medical 
Society, in Special Session at Detroit, Michigan, on 
January 8, 1939, herewith resolves that the physicians of 
the State of Michigan regret that any organization with 
the historical background and record of purposes and 
accomplishments as that of the American Medical Asso- 
ciation and which has so constantly directed its efforts 
toward the spread of education and scientific advancement 
for the health and welfare of the American people should 
be so summarily indicted. We, therefore, earnestly pledge 
our support in the hope that justice may be obtained. 

(Signed) Andrew P. Biddle, 

J. M. Robb, 

W. R. Torgerson, Chairman.” 

We move the adoption of this resolution. 

The motion was seconded by Dr. Harvey Hansen 
of Calhoun County and carried. 

Dr. J. A. Hookey (Wayne County) : I move 
that a copy of this resolution be sent by wire to 
the A.M.A. headquarters. 

The motion was seconded by Dr. R. L. Laird of 
Wayne County, put to a vote and carried. 

Reference Committee Report on Resolution 
Giving Authorization to the Council 
Re Finances 

The Speaker: Dr. Wiley, will you give us the 

report of your committee? 

Dr. H. W. Wiley (Ingham County) : Your 

Committee met and offers the following resolution: 

Resolved, That this House of Delegates express to the 
officers and councillors of the Michigan State Medical 
Society its confidence in the soundness of their delibera- 
tions and support any expenditures from the Treasury of 
the Society that seem in their judgment to be necessary. 
Furthermore, if additional funds are required in the 
pursuance or conduct of the Society’s activities, the Council 
be authorized to levy a capital assessment or assessments, 
not to exceed a total of $5 for the current fiscal year, 
as seem justified in their considered opinion. 

(Signed) Harold W. Wiley, Chairman, 

R. C. Perkins, 

Richard M. McKean. 

I move the adoption of this resolution. 

The motion was seconded by Dr. G. H. South- 
wick of Kent. 

The Speaker: You have heard the motion. Is 

there any discussion? 

The question was called for, the motion put to 
a vote and carried. 

The Speaker: Dr. Brasie, is your report ready? 

REFERENCE COMMITTEE ON REPORT 
OF THE COUNCIL 

Dr. Donald R. Brasie (Genesee County) : The 
Reference Committee on Reports of the Council, 
after due consideration and full appreciation of the 
efforts expended by the Council upon the report of 
group hospital service and group medical care plans, 
advise acceptance of the report. 

With reference to the Council’s recommendation 
for action, this Committee recommends that before 
any plan be finally adopted, said plan be submitted 
by mail for a vote by the individual members of 
the Michigan State Medical Society. 

Mr. Speaker, I move the acceptance and adoption 
of this report. 

February, 1939 


The motion was seconded by Dr. James J. 
O’Meara of Jackson County. 

The Speaker: It has been moved and seconded 

that this report be adopted. Is there any discus- 
sion on it? This is quite an important thing. 

A re-reading of the report was called for by one 
of the delegates. 

Dr. Brasie : Mr. Speaker, I move we go into 

executive session. 

The motion was seconded by Dr. A. V. Wenger 
of Kent County. 

The motion was carried. 

The House of Delegates went into Executive 
Session and discussed the report of the Reference 
Committee on The Council’s Report. 

Thereafter, the House arose from Executive Ses- 
sion, on motion of Drs. T. K. Gruber — W. Joe 
Smith. 

REFERENCE COMMITTEE ON OFFICERS’ 
REPORTS 

Dr. F. J. O’Donnell (Alpena) : This is the 

Report of the Reference Committee on Officers’ 
Reports. 

Your Committee has perused the reports of the 
President and the Speaker of the House of Dele- 
gates and wishes to commend them on the firmness 
of their convictions and the clarity of their state- 
ment of the problems confronting the profession. 

We also wish to express our appreciation to 
the officers of our Society for their untiring ef- 
forts, physical and mental exertion, and personal 
expenditures involved in behalf of the Michigan 
State Society. 

Respectfully submitted, Drs. Harkness, Day, 
Catherwood and O’Donnell. 

I move the adoption of the report. 

The motion was seconded by Dr. Southwick of 
Kent County and Dr. John A. Wessinger of Wash- 
tenaw County, put to a vote and carried. 

The Speaker: Are the two gentlemen repre- 

senting the National Medical Association here? 
Will Dr. Owens and Dr. Carney please come for- 
ward? 

Dr. E. R. Carney and Dr. S. H. C. Owens came 
to the front of the room. 

The Speaker : These gentlemen are delegates 

here from the National Medical Association. They 
were at the special session of the House of Dele- 
gates of the A.M.A. in Chicago, and have decided 
to cast their lot along with us. I would like to 
have them take a bow, and maybe one of them 
could talk for a few minutes. (Applause) 

Dr. E. R. Carney : Mr. Chairman and Members 

of the House of Delegates of the Michigan State 
Medical Society: We consider it a rare privilege 

to have the honor of sitting with you, listening 
to your resolutions and deliberations on hospital 
insurance. 

I happen to be the President of the National 
Hospital Association, representing 110 Negro hos- 
pitals in the United States. These are located 
principally in the South, as you know. I have 
visited in the past year seventy-seven of these hos- 
pitals. Naturally we are interested in any type of 
insurance. The 4,000 Negro doctors in the United 
States, dentists and pharmacists are interested also. 
We are interested in our security. Naturally we 
feel that any type of insurance that is passed by 
any state will be beneficial to the 12,000,000 Negroes 
in the United States, and 9,000,000 of those are 
located in the South, where medical care and 
hospital facilities are limited. 

We are grateful for this opportunity, and we 
sincerely hope to coopeiate with you in every pos- 


161 


SPECIAL SESSION— HOUSE OF DELEGATES 


sible way. We feel it is quite a privilege to be 
here. Thank you. (Applause) 

The Speaker: Thank you, Dr. Carney. 

Will Dr. Insley come forward and give his re- 
port? 

REFERENCE COMMITTEE ON REPORT 

OF COMMITTEE ON DISTRIBUTION 
OF MEDICAL CARE 

Dr. S. W. Insley: The matters contained in the 

material presented by Dr. Pino’s committee have 
been considered, and your Committee begs to re- 
port as follows : 

It has reaffirmed the principles endorsed by 
this body last September, relative to group hos- 
pitalization and sickness insurance schemes and 
recommends that all future action in group hos- 
pital and medical service plans conform to these 
principles. 

It then considered separately, for purposes of 
clarity, first, Group Hospitalization, and second, 
Group Medical Service. 

Group Hospitalization 

Your Reference Committee recommends, by a 
majority vote, that the Committee on Distribu- 
tion of Medical Care continue its efforts with the 
Michigan Hospital Association and the represen- 
tatives of labor, industry, agriculture, religious 
and educational organizations, community coun- 
cils and other interested groups to obtain a non- 
profit group hospitalization plan, sponsored joint- 
ly by the medical profession, the hospitals and 
the public. 

Secondly, it is further recommended that the 
Council be empowered to cooperate with or as- 
similate any one or more of the group hospitali- 
zation organizations which are now formed or 
may be formed to transact such business. 

Group Medical Care 

Your Reference Committee, by a majority vote, 
recommended that we empower the Council to 
cooperate with labor, industry, agriculture, reli- 
gious and educational organizations, community 
councils, and other interested groups, in the 
formation of a nonprofit group medical care 
organization. 

Dr. Torgerson : Didn’t the Committee have any 

recommendation on an enabling act? 

Dr. Insley: There was none made, Sir. 

The Speaker: You have heard the report of 

the Reference Committee. Is there anyone who 
wants to discuss this before a motion is made? 

Dr. B. R. Corbus (President-Elect) : I think 

it is an obligation which the President-Elect owes 
to you and to himself to express his own personal 
views, not in any way desiring to influence you. 
Dr. Luce has had an opportunity to express his 
views, with which I agree. 

We need hospital insurance. It is extremely 
desirable that we cooperate with laymen, various 
groups and hospitals toward the formation of such 
hospital insurance. 

I am pleased and happy to hear the report, so 
well delivered by Dr. Pino, in which he calls to 
your attention the possible seriousness of this So- 
ciety’s going into the hospital insurance business, 
but we need hospital insurance, the public needs 
it, and I am quite convinced that the diplomats 
in this organization, in their various home grounds, 
will be able to handle the situation, as was sug- 
gested in this resolution, so I am hoping that that 
resolution passes. 


Now, in regard to the next, it has seemed to 
me that it is imperative for us to take very direct 
action on this question of health insurance. Various 
complications I am sure can be ironed out. This 
has been up before. It was up several years ago. 

I think that many of us feel that it is very re- 
grettable that we did not do this experimental 
work. It would have saved perhaps the situa- 
tion that the American Medical Association finds 
itself in at the present time. I don’t see any 
dangers in it. Whereas this organization taking 
up hospital insurance must have a bank of cash 
reserve, in taking up this health insurance we 
have a bank of professional service reserve upon 
which we can draw, and after all the bank is 
drawn upon under our ethical standards all the 
time. 

I am particularly pleased with the unit system, 
where a doctor is in competition with his fellow 
doctor, and where the individual has the privilege 
of choosing his doctor, and if that doctor does 
not give good service he goes to another doctor, 
who gives better service. So the quality and 
standard, because of the competition, is maintained. 

I hope that you will consider this very care- 
fully. I want you to know my view. I feel certain 
that it can be worked out in a satisfactory way, 
and I feel more, that it is imperative that you 
take action now. (Applause) 

Councilor F. T. Andrews : May I have the 

floor? 

The Speaker: You may. 

Councilor Andrews : In bringing up this resolu- 
tion, I was concerned with the word “cooperation.” 
It is my interpretation that cooperation with these 
insurance companies ties the hands of the Council 
in a very drastic manner, in a manner in which 
I feel that we cannot carry on the desire of you 
men. I feel that it does not convey the sentiment 
of this organization when you tie our hands and 
don’t allow us to go on as you and other men 
throughout the state see fit. In other words, I 
feel that this doesn’t accomplish anything. 

Dr. J. A. Hookey (Wayne County) : I don’t 

quite understand what Dr. Insley’s committee means 
in their report. In the report of the Committee 
on Distribution of Medical Care, with reference 
to hospital insurance, they ask three questions. 
The first is whether they should continue efforts 
with the Michigan Hospital Association and the 
various other groups in an effort to form a non- 
profit plan. They recommend that we do that. 
At the same time, the Committee on Distribution 
of Medical Care asked if we were to assimilate or 
affiliate with one of the groups that are already 
in operation, and it seemed to me that they recom- 
mended that. Is that what that means? Does 
it mean that we are to take in one of these groups 
that are already operating? 

Dr. Insley : My understanding of the Com- 

mittee’s action was that it simply gave the Council 
the power to make such a move if they thought 
it desirable at some future date. 

Dr. Hookeys You mean the Council decides one 
way or the other? 

Dr. Pino: May I explain something to that 

point? There are companies already in existence 
who have started this. They can see that if 
they are going to be truly nonprofit and in the 
interest of all it would be a good thing to enter 
into a general program in the public good and be 
willing to lose their identity in this group, which 
would be a very good thing under certain circum- 
stances. We are only asking that the Council be 
given the power to take them in if they so see fit. 

Does that answer your question, Dr. Andrews? 

Jour. M.S.M.S. 


162 


SPECIAL SESSION— HOUSE OF DELEGATES 


Councilor Andrews: Not according to my un- 

derstanding of your resolution. 

I I Dr. Pino : Would you like to have Dr. Insley 

read it again? 

Councilor Andrews : I think I have the im- 

port of it, but I still feel that that word “cooper- 
ate” is a word which binds us to cooperate and 
not set up or take in any other organization that 
we might see fit. 

Dr. Pino: If it says cooperate or assimilate, 

at any rate they use their judgment. They may 
come to a standstill and say, “Maybe we had better 
go ahead and continue with that group.” For 
instance, here is this hospital group who have set 
up and gone a great way. They may finally say, 
“We will go along with you, as you wish.” In 
that case, don’t we want the Council to go along 
with that hospital group? That is the intent, Dr. 
Andrews. 

Councilor Andrews : I think the intent is there, 
but I don’t like the wording. 

The Speaker: I think we should take this sub- 

ject up in two divisions. There are two recom- 
mendations in that report. Will you read the 
first recommendation regarding hospital insurance 
and make a motion for its adoption so we can get 
our feet on the ground? 

Dr. Insley repeated that part of his report cover- 
ing Group Hospitalization. 

I move the adoption of this part of the report 
pertaining, as it does, to group hospitalization only. 

The motion was seconded by Dr. Torgerson of 
Kent. 

Councilor Roy H. Holmes (Muskegon County) : 
Is there a minority report? I notice he said it 
was endorsed by a majority of the Committee. 
If there is a minority report, I would like to hear 
it. 

Dr. Insley : In endeavoring to expedite matters 

this afternoon, I simply had time to write the ma- 
jority report. I myself, and I believe at least one 
more member, could very well have written a 
minority report. We haven’t had the time. 

Councilor Holmes : Could you give us that 

in substance? 

Dr. Insley : It is this in substance : It is not 

in the form of a motion. I am not particularly 
opposed to group hospitalization and some of the 
matters which have been stated here this afternoon. 
I feel that covers a large part of the catastrophic 
type of illnesses. However, I am not so sure 
that at this time we have to bind ourselves into 
promoting an organization or corporation to take 
up sickness insurance. 

The Speaker: The question was on a minority 

report on group hospitalization. 

Dr. Insley : I have no particular statement to 

make on group hospitalization. 

The Speaker: There is a motion before the 

House that we adopt the Committee’s recommenda- 
tion on group hospitalization. It has been seconded. 
Is there any further discussion on it? 

Dr. Gruber ; I wish to amend the first portion 
of the first recommendation by substituting “the 
Council of the Michigan State Medical Society” 
for “the Committee on Distribution of Medical 
Care.” 

The motion was seconded by Dr. Pino. 

The Speaker: It has been moved that the 

words “the Committee on Distribution of Medical 
Care” be changed and “the Council of the Michigan 
State Medical Society” substituted therefor. It 
has been supported. Is there any discussion on 
that? 

President Luce: May I ask that that be written 
on the blackboard. 


The motion and the suggested amendment were 
written on the blackboard by Dr. Foster. 

Dr. Torgerson : If the amendment carries, won’t 

the Committee on Distribution of Medical Care 
have any further part in it? 

The Speaker: Not on hospitalization. This 

directs the Council to go ahead and do something 
about it. 

Dr. Urmston: I assure you the Council is not 

going ahead with this without the support and 
advice of the Committee on Distribution of Medi- 
cal Care in any action we might take. It simply 
gives you the first part for the continued study 
on medical care, and the second part says the 
Council should go ahead and organize. We would 
perhaps continue for maybe a month before they 
would report to us. In that way we would take 
it up with the Committee and continue. It is 
all for your own interest. This gives us permis- 
sion to tell them to go ahead and do this and 
do that and report to us and we will form this 
organization as you wish. 

Dr. Torgerson : I wanted to suggest that we 

put in the words “the Committee on Distribution 
of Medical Care and the Council.” 

Dr. F. J. O’Donnell (Alpena County) : This 

amendment was seconded by the Chairman of the 
Committee on Distribution of Medical Care and I 
myself have the utmost confidence in him that he 
will go along with the Council on it. 

The Speaker: There is an amendment here. 

The amendment was put to a vote and carried. 

Councilor Wilfred Haughey (Calhoun) : Our 

Committee on Distribution of Medical Care has 
struggled for a long time with that hospital group. 
Now we substitute the Council for the Committee 
on Distribution of Medical Care, and that is all 
right. Why not strike out the words “continue 
its efforts” and put in the word “invite” the 
Michigan Hospital Association to cooperate with 
us. That means we are ready to go ahead and 
maybe we can get them to come to us. 

Dr. C. E. Simpson (Wayne County) : I move 

that the recommendations made by the Councillor 
be embodied as an amendment to this report, to 
strike out the words “continue its efforts with” 
and substitute “invite.” 

There was no second to this motion. 

The Speaker: Have you all read the report 

on the blackboard? There has been a motion 
made and seconded that this be adopted. It is 
all on group hospitalization. 

The motion was put to a vote and carried and 
the recomendation on group hospitalization was 
adopted as amended. 

The Speaker: The second portion of Dr. Insley’s 
report — and he has gone down to get a cup of 
coffee — is very short. Will you read it, Dr. 
Foster? 

Dr. Foster read the Reference Committee’s re- 
port. 

Dr. McClelland (Wayne County) : I move it 

be adopted. 

The motion was seconded by Dr. John A. Wes- 
singer of Washtenaw County. 

The Speaker: Is there any discussion on this 

motion? 

Dr. R. J. Hubbell (Kalamazoo County) : May 

I ask a question? Does this recommendation mean 
to include possible care of indigents in certain 
communities? I think our Society is going to ask 
me what was done here on the care of the indi- 
gent. 

The Speaker: I think I will answer that myself. 

There is nothing here on the care of indigents 


February, 1939 


163 


SPECIAL SESSION— HOUSE OF DELEGATES 


unless somebody takes advantage of this plan 
and buys some medical service for the indigent. 

Dr. Andrew P. Biddle (Wayne County) : Does 

this include professional care by the physician and 
all hospital service and everything? 

The Speaker: Your hospitalization is taken 

care of there. This refers to medical care. 

Dr. Biddle: In what way? 

Secretary Foster: I will read it again. (Re- 

reading the recommendation on medical care) 

Dr. R. M. McKean (Wayne County) : May I 

amend that by adding at the end, “along the general 
lines laid down by the Committee on Distribution 
of Medical Care.” 

The Speaker: Is there a second to that? 

There was no second. 

Dr. H. Huntington (Livingston County) : I 

think if the member will notice, the preamble to 
this report said we reaffirm the principles of 
medical care, and that is all taken care of in the 
preamble of the report. 

Dr. H. W. Wiley (Ingham County) : Does this 

mean the Michigan State Medical Society is on 
record as going into the insurance business? 

Several delegates said “No.” 

Dr. James J. O’Meara (Jackson County) : Does 

this mean that I have to go back to my county 
society and tell them the Council is going to set 
up some system whereby we are going to tell 
all the practitioners in the County of Jackson what 
they can charge and how much they should charge 
for each individual case? 

Several Delegates : No. 

Dr. O’Meara: What does it mean then? 

The Speaker: Yes, I believe it does mean that. 

Dr. O’Meara: If it means anything like that, I 

don’t think we are entitled or empowered to do it. 

I am down here as one representative — the 
Speaker is the other — of approximately one hun- 
dred doctors in the County of Jackson. They told 
me specifically to come down here and fight any 
set plan which is going to help to lead us into 
state medicine. If we put any plan like this into 
organization it is going to help for more socialized 
medicine. I think before we as delegates act for 
the rest of the 4,000 members throughout the 
State of Michigan, they should have a chance to 
vote on it themselves so they will know what 
their delegates are trying to do for them. 

Dr. C. S. Kennedy (Wayne County) : I rise, 

as an Irishman, to support another Irishman. I 
think his position is well taken. I am sorry Dr. 
Insley is not here to present his minority report. 
I am afraid that is exactly where we are heading. 
Consequently I am opposed to it. 

Dr. Donald R. Brasie (Genesee County) : This 

is exactly what our Committee referred to, the 
wording there. As I understand it, if you pass 
that resolution you definitely empower the Council 
to form a nonprofit group medical organization. 
As much as we like the Council and trust them 
and know they are doing a very excellent job — 
and I don’t tbink anyone criticizes that— you are 
giving them a blank check to underwrite any type 
of organization they see fit. I am not arguing 
about their judgment.. It is undoubtedly better than 
mine and maybe better than that of the organiza- 
tion as a whole, but that is not the democratic 
way of doing things. 

If we are going to have this kind of organiza- 
tion with all that it implies, then the members 
of the State Society as a whole should have the 
right to say whether or not they want it. 

If it is necessary here to amend this particular 
resolution at this time to say that before any final 
action is taken definitely and before the Society 

164 


definitely commits itself to an organization plan, 
the members of the Society be given a vote on 
it, I will offer that amendment. 

I move that we amend that recommendation to 
state that before it is definitely sanctioned by the 
Council of the State Medical Society it be re- 
ferred to the members of the Michigan State Medi- 
cal Society at large by a vote by mail. 

Dr. McClelland (Wayne County) : I will with- 

draw my original motion on the resolution and 
ask that as a substitute, with the consent of my 
second, this be laid on the table until such action 
as Dr. Brasie has suggested be taken. 

Dr. O’Meara : Gentlemen, you are not talking 

only for yourselves. Lots of us have sons. I 
have. Perhaps they are going to be doctors. I 
know one of mine is. We are not only taking 
action on our own livelihood ; we are taking action 
on our second, third, fourth and fifth generation. 
It is a serious thing. I don’t think we as individ- 
uals here, on such short notice, should take action 
on it. I think all the members of the State Medi- 
cal Society should have a vote. 

Dr. Holly (Muskegon County) : I quite agree 

with all that has been said about the members of 
the Michigan State Medical Society having an op- 
portunity to vote on this action that has been taken 
today. On the other hand, having had rather 
intimate contact with several members of the Coun- 
cil, knowing their attitude regarding medical mat- 
ters as they affect you and me and everybody 
else, and having listened to threats by certain 
representatives of so-called medical practice at the 
last meeting in September, I would much prefer 
to put my confidence and my trust in the members 
of the Council as it is now constituted than to 
try to get some 4,000 doctors to give ideas on 
what is going to be done or what should be done. 

The point is, whether we like it or not, we are 
going to have either socialized medicine by govern- 
ment, or we are going to have some form of 
medical service to the low-income group recom- 
mended by men like we have in our Council, and 
I for one would rather throw my lot with the 
Council than I would to throw it in Washington 
where we are going to have it if we don’t take 
some action ourselves. 

Dr. Frank E. Reeder (Genesee County) : Mr. 

Speaker, I would like the Speaker to call upon 
Dr. Luce and ask him to discuss for us once 
more, in a few words, the sentiment of the House 
of Delegates of the American Medical Association 
in Chicago last September on this very question. 

The Speaker: Dr. Luce, can you recollect that? 

President Luce: Mr. Speaker and Members of 

the House of Delegates : I assume that we are 

practically in executive session. I know my re- 
marks this morning were very ambiguous. 

May I ask, as a matter of information, if all 
present are members of the organized medical 
profession of the State of Michigan? 

The Speaker: No, we are not in executive 

session. 

President Luce: If you want me to say what 

I wanted to say this morning, I would prefer 
to say it in executive session. 

Dr. Gruber : I move the House of Delegates of 

the Michigan State Medical Society go into execu- 
tive session. 

The motion was seconded by Dr. Biddle of 
Wayne County and carried. 

The House of Delegates went into Executive 
Session, and, after full discussion, adopted the 
recommendation on voluntary group medical care 
as submitted by the Reference Committee on re- 
ports of Standing Committees, as follows : 

Jour. M.S.M.S. 


SPECIAL SESSION— HOUSE OF DELEGATES 


Group Medical Care 

Your Reference Committee by a majority vote 
recommends that we empower The Council to 
cooperate with labor, industry, agriculture, reli- 
gious and educational organizations, community 
councils, and other interested groups in the for- 
mation of a non-profit group medical care organi- 
zation. 

REFERENCE COMMITTEE ON REPORT 

OF THE COUNCIL 

The report of the Reference Committee on The 
Council’s Report was thoroughly discussed, and 
was not adopted. 

ENABLING LEGISLATION 

The following motion re enabling acts was adopted 
by The House of Delegates on motion of Drs. 
T. K. Gruber, Wm. R. Torgerson : 

The Council of the Michigan State Medical 
Society is empowered to use its judgment in the 
matter of cooperating in introducing necessary 
legislation in the Legislature of the State of 
Michigan at the present session to make it possi- 
ble to legally handle both group hospitalization 
and group health insurance. 

Following is the resume of the actions of the 
House of Delegates : 

The House of Delegates of the Michigan State 
Medical Society: 

1st — approved the principles of Voluntary 
Group Hospitalization 

2nd — approved the principles of Voluntary 
Group Medical Service 

and — empowered The Council in cooperation 
with the hospitals and civic groups to proceed 
with the establishment of plans embodied in the 
above principles. 

Report of Reference Committee on Reports of 

Standing Committees: 

(Approved by the House of Delegates) 

“The matters contained in the material pre- 
sented by the Committee on Distribution of Med- 
ical Care have been considered and your Refer- 
ence Committee begs to report as follows: It 
has re-affirmed the principles endorsed by this 
body last September relative to group hospitali- 
zation and sickness insurance schemes and rec- 
ommends that all future action in group hospital 
and medical service plans conform to these prin- 
ciples. 

“It then considered separately for purposes of 
clarity (1) group hospitalization and (2) group 
medical service. 

Group Hospitalization 

“Your Reference Committee recommends: 

“(1) That The Council continue its efforts with 
the Michigan Hospital Association and the rep- 
resentatives of labor, industry, agriculture, reli- 
gious and educational organizations, community 
councils, and other interested groups to obtain a 
non-profit group hospitalization plan sponsored 
jointly by the medical profession, the hospitals 
and the public. 

“(2) It is further recommended that The Coun- 
cil be empowered to cooperate with or assimilate 
any one or more of the group hospitalization or- 
ganizations which are now formed and may be 
formed to transact such business. 

Group Medical Care 

“Your Reference Committee by a majority vote 
recommends that we empower The Council to 

February, 1939 


cooperate with labor, industry, agriculture, reli- 
gious and educational organizations, community 
councils, and other interested groups in the for- 
mation of a non-profit group medical care organ- 
ization.” 

* % * 

Additional motion passed by the House of 
Delegates: 

“The Council of the Michigan State Medical 
Society is empowered to use its judgment in the 
matter of cooperating in introducing necessary 
legislation in the Legislature of the State of 
Michigan at the present session to make it possi- 
ble to legally handle both group hospitalization 
and group health insurance.” 

ELECTION OF ALTERNATE DELEGATE 

The House of Delegates unanimously elected 
Carl F. Snapp, M.D., of Grand Rapids, as alternate 
delegate to take the place of James J. O’Meara, 
M.D., resigned, on motion of Drs. A. T. Hafford, 
W. Joe Smith. 

DR. PINO THANKED 

A rising vote of thanks was extended to Ralph 
H. Pino, M.D. “for his untiring efforts, his loyalty, 
his integrity, and his interest in the medical pro- 
fession,” motion of Drs. D. R. Brasie, Carl F. 
Snapp. 

The House of Delegates was adjourned at 5 :40 
p. m. 


HEALTH PLAN TO CONGRESS 

The Detroit News published this practical 
editorial on January 25: 

“Studies of the needs and the developing move- 
ment for providing good medical care more widely 
have been fully reported and sympathetically treated 
editorially in The News for years. President Roose- 
velt now transmits ‘for the careful study of Con- 
gress’ the report by his Interdepartmental Commit- 
tee to Coordinate Health and Welfare Activities. 

“Except for a feature involving a form of com- 
pulsory health insurance, the program for an even 
division of the costs between the States and the na- 
tional Government and for a Federal-State adminis- 
tration of all health services probably has general 
support in the medical world and would be a step 
onward in social progress. 

“But the attractions can not be regarded as the 
controlling consideration at this time. The cost for 
a first year would be $100,000,000. After 10 years, 
the costs are probably underestimated at $850,000,- 
000. As money matters stand in national financing 
and in most states, where would the additional great 
sums come from? 

“As time has gone on, with the subject kept be- 
fore the public, state medical societies, Michigan’s 
among others, have taken progressive steps to assist 
better in serving patients unable to pay anything 
and to provide for low-cost facilities for the low- 
income classes. These efforts will be tested if adop- 
tion of a Government system rests in abeyance. 

“Although on the whole speaking favorably, the 
President did not urge immediate legislation. It 
may be his admission of the regrettable fact that the 
assumption of this major additional public expense 
is not at present safely practicable. All the prom- 
ising things can not be done quickly. This is one 
which surely would best await a national income 
restored to the prosperity level, with the national 
Treasury extricated from its desperate straits.” 


165 


4 WOMAN'S AUXILIARY 4 

President — Mrs. P. R. Urmston, 1862 McKinley Avenue, Bay City, Michigan 
Sec.-Treas. — Mrs. R. E. Scrafford, 2210 McKinley Ave., Bay City ; Michigan 
Press — Mrs. J. W. Page, 119 N. Wisner Street, Jackson, Michigan 


ORGANIZATION COMMITTEE 

On Tuesday, December 13, 1938, at the home of 
Mrs. Alvin Thompson of Flint, the Woman’s Auxil- 
iary to the Genesee County Medical Society was 
formed. Two weeks previously at a preliminary 
meeting attended by the 
state president, Mrs. P. 
R. Urmston, and Mrs. R. 
E. Scrafford, state secre- 
tary-treasurer, both from 
Bay City, Mrs. J. A. 
Spencer of Flint had been 
appointed temporary 
chairman. 

At the meeting held at 
Mrs. Thompson’s, Mrs. 
Spencer presided. After a 
short talk by Mrs. Roger 
V. Walker of Detroit, 
chairman of the Organi- 
zation Committee for the 
State, on the reasons for 
forming an Auxiliary, a 
vote was taken. The deci- 
sion reached was that an Auxiliary should be or- 
ganized. The following officers were elected : 

President — Mrs. Gordon L. Willoughby, Flint. 

Vice President — Mrs. Alvin Thompson, Flint. 

Secretary — Mrs. James A. Olson, Flint. 

Treasurer — Mrs. T. Sidney Conover, Flint. 

In December, the wives of the members of the 
Houghton-Baraga-Keweenaw Medical Society were 
invited to attend a dinner meeting of this Society. 
The subject of the organization of an Auxiliary 
was discussed, and Mrs. L. E. Coffin of Painesdale 
presented briefly some facts concerning the organ- 
ization of an Auxiliary. There was considerable 
interest shown, and another meeting has been 
planned at which time it is hoped that an Auxiliary 
will be formed. We are deeply indebted to Dr. 
George McL. Waldie of Houghton for his help in 
arousing interest in the formation of an Auxiliary, 
and for all the help which he has rendered. 

We hope, before the year is up, that there will 
be several more Auxiliaries formed. Mrs. L. Fer- 
nald Foster of Bay City, Mrs. A. V. Wenger of 
Grand Rapids, and Mrs. W. W. Lang of Kalamazoo 
have consented to assist the chairman of this com- 
mittee, thus making it more nearly possible for some 
committee member to be near enough most of the 
organizing Auxiliaries to attend a meeting. 

Respectfully submitted, 

Helen R. Walker (Mrs. R. V.) 

Organisation Chairman. 


Jackson County Auxiliary 

The following toast was given by Dr. Rex Bullen, 
president of the Jackson County Medical Associa- 
tion, at the annual banquet in December when the 
doctors brought their wives as guests : 

THE DOCTOR’S WIFE 

’Tis generally thought by intelligent folks that the doctor 
is quite a man ; 

They know he studies and works and sweats and does the 
best he can. 

In the complicated plan of life he plays a useful part 

Relieving human suffering with his science and his art. 


He is recognized as a gentleman of learning and renown 

A credit to his country, his family and his town. 

And I’m not taking from him any laurels he has known 

When I call your kind attention to his “power behind the 
throne.” 

She took him as a partner for weal or else for woe, 

Not knowing what direction or how far he might go. 

Did she waver because he was in debt, with a car that 
would hardly run 

And had to live in a furnished flat and buy coal by half 
a ton? 

Did she send him away to go make a name, to return when 
he’d won his spurs, 

When he could come back and shower her with diamonds 
and cars and furs? 

Ah no ! With a smile upon her lips and a brave little tilt 
of her chin 

She said, “We are partners in winning our spurs,” and she 
started from scratch with him. 

She sewed and. washed and ironed his shirts and answered 
the telephone 

And while the doctor fought the good fight, he didn’t fight 

it alone. 

She sympathized when he lost a case in spite of the best 
he could give 

Of study and thought and work and prayer, to make a 
patient live. 

She cushioned his head against her breast and ran her 
hands through his hair, 

And God! how it helps in a time like that to have someone 
to care ! 

Through all the years she has been his pal, his counsellor 
and his friend, 

His joys and his sorrows have all been hers and will be 
to the end. 

And so, my brother physicians, I should like to propose a 

toast 

To one who has stuck through thick and thin and never 
deserted her post, 

To one who is tender and brave and true and dearer to us 
than life ; 

With all the sincerity and love in our hearts, a toast to the 
doctor’s wife. 


Kent County Auxiliary 

“On Borrowed Time,” the fanciful play bj- Paul 
Osborn which paradoxically deals the hurt of death 
and yet teaches its tremendous value, was capably 
read at the December meeting of the Kent County 
Medical Auxiliary. One of the popular hits seen on 
Broadway during the 1937-1938 season, this curious- 
ly satisfying comedy about death was dramatized 
by Air. Osborn from the story by Lawrence Edward 
Watkin, and tells of an old man who chased death 
up a tree and held him there while he tried to find 
a suitable home for his grandson. 

Widely acclaimed by critics, which in itself is 
unusual, “On Borrowed Time” has, perhaps, a more 
universal appeal than its contemporary plays, “Our 
Town” and “Shadow and Substance,” which also 
dealt with a metaphysical subject. 

Aluch credit should be given Airs. Ralph L. Fitts 
who directed the performance for the verve with 
which the lines were read and for her choice in 
the selection of “actresses” who so ably adapted 
themselves to character. In addition to her role 
as directress, Airs. Fitts read convincingly the diffi- 
cult lines given to “Gramp.” Equal credit, of 
course, goes to our other members taking part who 
included Airs. Dewey R. Heetderks, Mrs. L. Paul 
Ralph, Airs. Leon DeVel, Airs. Lucien S. Griffith, 

Jour. M.S.M.S 



Mrs. Walker 


166 



WOMAN’S AUXILIARY 


Mrs. Luther Carpenter and Mrs. William J. Butler, 
our president. 

Following the reading of the play tea was served 
with Mrs. Torrence L. Reed and Mrs. Charles F. In- 
gersoll as hostesses. Mrs. John T. Hodgen and 
Mrs. P. L. Thompson presided at the tea table which 
was beautifully and appropriately arranged with the 
gay decorations of Old St. Nick. Also adding to 
the pleasure of the occasion was the presence of a 
large delegation from the Ottawa auxiliary. 

On Friday, January 6, members of the Hygeia 
and Philanthropic committees were entertained at an 
open tea in the home of Mrs. Carl F. Snapp. The 
affair was called a “Visit to Persia” and the rooms 
were elaborately decorated in keeping with the 
home. Persian coffee and various kinds of oriental 
food were served. Co-chairmen are the committee 
heads, Mrs. Joseph C. Tiffany and Mrs. Wallace H. 
Steffensen. 

Jane R. Frantz 
Press Chairman. 


Kalamazoo County 

Covers were placed for one hundred and twenty- 
five at dinner at the Columbia Hotel on December 
20, when members of the Woman’s Auxiliary were 
guests of the Academy of Medicine. Dr. Homer 
Stryker, of the University Hospital of Ann Arbor, 
acted as toastmaster. Dr. Ralph B. Fast, newly 
elected president of the Academy spoke briefly. 
Mrs. F. M. Doyle, president of the Auxiliary, ex- 
tended greetings to the Academy. She also told 
the aims of the Auxiliary and mentioned that just 
eleven years ago on the same date the Auxiliary 
was organized. Dr. F. T. Andrews spoke of the 
splendid work recently completed by Dr. Rush Mc- 
Nair in his book, “Medical Memoirs,” which tells 
interesting personal reminiscences of fifty years of 
medical practice in Kalamazoo. Tribute was paid 
to Dr. McNair by the group. 

Dr. B. I. Beverly, of Rush Medical College, then 
lectured on “Psychiatry of Children” which was 
intensely interesting. 

A social evening followed with bingo, bridge and 
dancing as diversions. 

(Mrs. Hugo) Barbara K. Aach 
Publicity Chairman. 


Doctors Get in Step 

(Bay City Times) 

The doctors of Michigan got in step with modern 
thought Sunday when the house of delegates of the 
state society voted in favor of cheap group medical 
service for the low-income families. There were 
indications earlier that they would oppose the plan, 
and insist on conditions being allowed to continue as 
they are. 

If their present policy works out it is to be ex- 
pected that sufficient hospital and medical care will 
be placed within the reach of all families with an 
income of $1,500 a year or less. Necessity of this 
reform has long been recognized, but up to the pres- 
ent has been opposed by most groups of organized 
physicians, and even now is regarded with more or 
less hostility by the national organization. 

The service, if and when it is put into effect, will 
be financed by group insurance, the details of which 
are being studied. It is expected that it will do 
much to improve Michigan health conditions and 
should relieve a million poor families of one of 
their economic nightmares, illness which they are 
not in a financial condition to combat. 

This movement marks a cheering advance in the 
relations of this great profession with the public on 
which it is to be congratulated and applauded. 

February, 1939 



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For free samples and literature, send 
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167 






MICHIGAN’S DEPARTMENT OF HEALTH 


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MICHIGAN’S DEPARTMENT 
OF HEALTH 

DON W. GUDAKUNST, M.D., Commissioner 

LANSING, MICHIGAN 


THE HEALTH OF THE STATE IN 1938 

A review o£ the health of Michigan during 1938 
reveals many optimistic trends. The general death 
rate is down — the lowest in history with the excep- 
tion of 1932 and 1933. The birth rate is up — the 
highest since 1930. The infant mortality rate is the 
lowest ever. The maternal mortality rate is equal 
to the all-time low record established in 1937. 

These conclusions are based upon provisional sta- 
tistics for the first ten months of 1938. During that 
period 41,707 deaths were reported compared to 
44,819 during a similar period in 1937 — a decline 
of approximately seven per cent. This means a 
death rate of 9.8 per 1,000 population, dropping from 
10.6 the previous year. Births jumped from 76,435 
last year to 80,590 during the first ten months of 
1938. This means an excess of 38,883 births over 
deaths in that period. 

The new all-time low infant mortality rate ac- 
counted for 3,564 infant deaths in 1938 compared 
with 3,673 in 1937. The provisional infant death 
rate this year is 44.2 deaths per 1,000 live births. 
The maternal mortality rate of 3.6 deaths of mothers 
per 1,000 live births is identical with that for 1937. 
There were 291 deaths of mothers from causes con- 
nected with childbirth this year. 

As for the specific causes of death, the first three 
major causes including heart disease, cancer and 
apoplexy are continuing on the upswing, their com- 
bined mortality accounting for more than one-third 
of all deaths. All other major causes of death, 
however, show declining trends. Pneumonia, auto- 
mobile and other accidents, tuberculosis and nephritis 
lead the way in this decline. Deaths from pneu- 
monia dropped from 3,403 in 1937 to 2,271 this year. 
The concerted drive upon automobile accidents this 
year has brought results. Deaths from this cause 
dropped from 1,825 during the first ten months of 
1937 to 1,139 this year — a saving of 686 lives. Mich- 
igan’s population for the determination of 1938 rates 
is estimated at 5,100,000. 

Outstanding developments in the activities of the 
Michigan Department of Health during 1938 for 
promoting the health of the state have included a 
marked expansion of public health services with the 
aid of federal funds, a reorganization of the admin- 
istrative set-up of the department, the launching of 
a campaign for the amelioration of the insanitary 
conditions existing in many rural and resort areas of 
the state, and the stimulation of activities for the 
provision of more adequate medical care for persons 
unable to pay for such care. A venereal disease 
program has been shaped which provides free 
laboratory examinations for the diagnosis of these 
diseases and free drugs for the treatment of all 
cases of syphilis. Under the law requiring pre- 
marital examinations for venereal diseases which 
went into effect a little over a year ago, 674 cases 
of syphilis have been discovered. The department 
has made 33,582 free diagnostic tests for syphilis 
in its administration of this law. 

Federal grants have made it possible to greatly 
expand maternal and child health protection services 
and to subsidize strong, full time local health de- 
partments. Two new county health departments 
were organized during the past year in Ingham and 
Muskegon counties. This makes a total of 58 coun- 

Iour. M.S.M.S. 


168 



MICHIGAN’S DEPARTMENT OF HEALTH 


ties now provided with such departments. In 1936 
when federal funds first became available for this 
purpose, there were 22 county and district health 
departments; today there are 36, serving 60 per cent 
of the rural population. More than three-fourths 
of the total population of the state are now pro- 
tected by full time health departments in urban and 
rural areas. It is through its advisory and super- 
visory activities in relation to these local health de- 
partments that the State Department of Health 
wields its greatest influence. 

A concerted effort has been made to bring tuber- 
culosis into the list of diseases that are no longer 
major causes of death. State-wide activities have 
been correlated and intensified for the location of 
early cases. Medical care has been made available 
for all cases regardless of ability to pay. Michigan 
laws were clarified and strengthened by the last 
legislature, thereby making it possible to provide 
prompt hospitalization. The state subsidy for county 
sanatoria has been doubled, thus relieving the bur- 
den of the poorer counties. Closer supervision has 
resulted in the improved administration of these 
sanatoria. 

The Michigan Department of Health maintains 
one of the finest public health laboratories in the 
nation. During the year just closed more than 
450,000 examinations for the diagnosis of com- 
municable diseases were made free of charge for 
health officers and physicians. The department was 
able to aid greatly in bringing to a halt the extensive 
outbreak of smallpox which occurred during the 
early part of 1938. This was done by producing in 
the Biologic Products Division vaccine for more 
than 750,000 smallpox vaccinations within a period 
of ninety days. The same has been true in meet- 
ing the unusual outbreak of rabies during the past 
summer and fall. More than 60,000 doses of rabies 


vaccine produced by the Department laboratories 
helped to prevent great loss of life from this cause. 
The laboratories, too, have completed a five year 
study of a vaccine for the prevention of whooping 
cough which has attracted national attention. Most 
favorable results have been reported through the 
use of this vaccine in preventing this frequently 
fatal disease of early childhood. 

Particular attention has been devoted to pneu- 
monia during 1938. A division of pneumonia con- 
trol has been established in the department. Typing 
and serum distributing stations have been established 
throughout the state. Research over a period of 
three years finally resulted in 1938 in the state-wide 
free distribution of improved serum for the treat- 
ment of Type 1 and Type 2 pneumonia. Serum for 
the treatment of other types is now being developed. 
Hope for a vaccine for the prevention of pneumonia 
has been spurred by seemingly successful experi- 
ments reported during the past year. 

Nearly three-quarters of the state’s population are 
now served by public water supplies and sewerage 
systems inspected and approved by this depart- 
ment. There has been a four-fold increase in plans 
submitted for approval of the construction of sew- 
age treatment and water purification plants. The 
insanitary conditions found in many rural areas, 
however, have been the source of extensive out- 
breaks of bacillary dysentery. Little has been done 
in the past to control the conditions causing this 
illness which tourists have begun to call the “Mich- 
igan disease.” A thorough investigation of the 
causes of these intestinal infections which threaten 
to curtail the tourist and resort trade has been 
started during the past summer. General insani- 
tary conditions such as those which contributed so 
largely to the extensive outbreak of Shiga dysen- 
tery in Shiawassee county last summer have been 



NATIONAL ASSOCIATION OF CHEWING GUM MANUFACTURERS, STATEN ISLAND, NEW. YORK 

February, 1939 169 


MICHIGAN’S DEPARTMENT OF HEALTH 




The Drake offers every luxury and convenience of fine 
living on Chicago's Gold Coast, overlooking Lake Michigan. 

A. S. Kirkeby, Managing Director 



The J) rata 

LAKE SHORE DRIVE -CHICAGO 





and will continue to be the object of attack by the 
state and local health departments. 


DR. W. J. V. DEACON DIES 

Dr. W. J. V. Deacon, director of the Bureau of 
Records and Statistics since it was first established 
in the Michigan Department of Health in 1921, died 
at his East Lansing home December 20, 1938. Dr. 
Deacon had been ill for three weeks. Death was 
caused by coronary occlusion and multiple coronary 
thrombosis. 

Born in New York City October 27, 1868, Dr. 
Deacon had already established his reputation as a 
vital statistician when he came to the Michigan De- 
partment of Health in 1919. He came to Michigan 
from Kansas where he had been state registrar of 
vital , statistics for the Kansas State Board of Health 
and assistant professor at the University of Kansas. 

Dr. Deacon’s efficient organization of Michigan’s 
8,250,000 vital records gained for this state a na- 
tional reputation for the completeness and avail- 
ability of its statistical information. Dr. Deacon 
was twice designated by the Secretary of State at 
Washington as a member of the International Com- 
mission on the Decennial Revision of the Nomen- 
clature of Diseases. In 1928 he went to Texas to 
aid that state in organizing its registration sys- 
tem for admission to the federal registration area. 

The many valuable statistical studies which Dr. 
Deacon made for numerous state and national pub- 
lications were the results of his vision of the im- 
portance of vital records in shaping the cotirse and 
testing the results of preventive medicine. Dr. 
Deacon was instrumental in the organization of the 
American Association of State Registration Execu- 
tives and served as its first president. He was a 
fellow of the American Public Health Association 

170 


and had been chairman of the vital statistics section. 
He was also executive officer of the Michigan Public 
Health Association from 1927 to 1931, becoming its 
president in 1932. 

At the time of his death, Dr. Deacon held the 
rank of lieutenant colonel in the army reserve. He 
will be buried beside his only son in Arlington 
National Cemetery. 


RADIUM LOANS AVAILABLE 
TO MICHIGAN 

Michigan hospitals, cancer clinics and medical 
centers are eligible to apply for the loan of radium 
from the National Cancer Institute which was estab- 
lished by congessional act August 5, 1937, with a 
$700,000 annual appropriation. In order to coordi- 
nate the work of the National Cancer Institute with 
the state cancer control program applications for 
the loan of radium will be approved by the Mich- 
igan Department of Health. 

Contracts for the loan of radium will be made 
for one year only, subject to renewal. Upon ex- 
piration of the contract, the radium must be re- 
turned to the National Cancer Institute in good 
condition in the same form and the same degree 
of radioactivity in which it was loaned. Prior to 
the shipment of radium, the applicant will be re- 
quired to take out and deposit with the National 
Cancer Institute an insurance policy protecting the 
government against all loss or damage to the radium. 
No charge can be made a patient for the use of gov- 
ernment owned radium. Preference must be given 
in the use of the radium to patients whose financial 
circumstances are such that they cannot, without de- 
priving themselves of the necessities of life, pay 
from their own resources for the cost of the use of 
radium. 


Jour. M.S.M.S. 


MICHIGAN’S DEPARTMENT OF HEALTH 


SUMMARY OF COMMUNICABLE 
DISEASE CASES IN 1938 

Measles led all other communicable diseases in 
prevalence in 1938, according to case reports re- 
ceived by the Bureau of Records and Statistics. I he 
measles outbreak of last year was the greatest in 
the history of the state, even outdistancing the 19 3b 
outbreak. Last year 79,393 cases of measles were 
reported compared to 79,061 in 1935. The five-year 
mean for the state is 23,243 cases per year. . 

Pneumonia cases, on the other hand, tumbled in 
the opposite direction to a new low of 2,601 cases, 
compared with 4,590 in 1937. Tuberculosis cases to- 
taled 6,263, compared with reports of 6,469 cases 
the previous year. , , . , in . 

Diphtheria case reports dropped back to 619 in 
1938 after rising to 842 the previous year. With the 
exception of the 614 cases reported in 1934, this 
was the lowest number of cases ever reported. 
Typhoid fever cases totaled 284, 39 of which oc- 
curred in one major outbreak. There were 241 
cases of typhoid reported in 1937. 

Whooping cough prevalence increased in 1938 on 
the basis of 14,513 case reports. The previous high 
total was reported in 1936 when 14,287 cases oc- 
curred. . 

The prevalence of other communicable diseases in 
1938 on the basis of provisional reports is as fol- 
lows : Scarlet fever, 18,303; smallpox, 274; menin- 
gitis, 69 ; poliomyelitis, 59 ; syphilis, 14,684 ; and 
gonorrhea, 7,046 cases. 


MONTHLY MORTALITY REVIEW 

Mortality reports for the first eleven months of 
1938 compiled by the Bureau of Records and Sta- 
tistics show a decline in total deaths from 48,922 in 
1937 to 45,837 this year. Infant mortality, too, is 
down from 4,008 in 1937 to 3,920 in 1938. Maternal 
deaths slightly exceed last year’s figures when an 
all-time low rate for this cause was set, but with 
the current increase in births, the 1938 maternal 
mortality rate will compare favorably. There were 
302 maternal deaths last year compared to 315 
this year. Births have increased from 83,873 in 
1937 to this year’s total of 87,947 for the eleven 
month period. 

Comparative mortality figures for the major com- 
municable diseases in 1937 and 1938 are indicated 
in the table below : 

COMMUNICABLE DISEASE MORTALITY 



1937- 

Nov. 

1938 

Nov. 

11 Months 

11 Months 


1938 

1937 

1938 

1937 

Pneumonia 

. 209 

312 

2,480 

3,715 

Tuberculosis 

. 127 

155 

1,744 

1,971 

Typhoid Fever . . . . 

4 

4 

23 

29 

Diphtheria 

6 

8 

39 

65 

Whooping Cough . . 

6 

7 

107 

l2i 

Scarlet Fever 

7 

6 

8 1 


Measles 

2 

0 

98 

9 

1 

39 

50 

0 

Smallpox 

0 

0 

0 

Meningitis 

1 

2 

19 

Poliomyelitis 

1 

2 

9 

1 

Undulant Fever.... 

0 

0 

Syphilis 

43 

36 

361 

364 

Gonorrhea 

1 

1 

7 



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February, 1939 



IN MEMORIAM 




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(In affiliation with COOK COUNTY HOSPITAL) 
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starting every week. Two Weeks Course in Internal 
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SURGERY— General Courses One, Two, Three and Six 
Months; Two Weeks Intensive Course in Surgical 
Technique with practice on living tissue; Clinical 
Courses; Special Courses. Courses start every Monday. 

GYNECOLOGY — Two Weeks Course starting February 
27, 1939. Clinical and Personal Courses starting every 
week. 

OBSTETRICS — Two Weeks Intensive Course starting 
March 13, 1939. Informal Course starting every week. 

FRACTURES & TRAUMATIC SURGERY— Informal 
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starting April 10, 1939. Informal Course starting 

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starting April 24, 1939. Informal Course starting every 
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IN ALL BRANCHES OF MEDICINE, SURGERY 
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ADDRESS: 

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IN MEMORIAM 


Dr. G. Warren Hyde 

Dr. G. Warren Hyde, of Detroit, died on Novem- 
ber 17, 1938. Dr. Hyde was bom in El Paso, Texas, 
on November 11, 1898, and had lived in Detroit since 
1904. He was graduated from the University of 
Michigan. During the war, he served under Dr. 
B. R. Shurly in Base Hospital Unit No. 36. He 
was a member of the psychological clinic of the 
Board of Education and was on the staff of Eloise, 
Harper and Shurly Hospitals. Dr. Hyde was Presi- 
dent of the Detroit Dermatological Society, Certified 
by the American Board of Dermatology and Syphi- 
lology, American Academy of Dermatology, and the 
Central States Dermatological Society. He was a 
former chairman of the Section of Dermatology and 
Syphilology of the Michigan State Medical Society. 
He is survived by his wife, a daughter, Patricia, 
and son, Michael. 


Dr. Frank Suggs 

Dr. Frank Suggs was born in Little Rock, Arkan- 
sas, and was graduated from the Arkansas Univer- 
sity Medical School in 1897. He served in the 
Medical Corps of the United States Army in Alaska 
and later in the Philippines. He was also a veteran 
of the Spanish-American and World Wars. Major 
Suggs was a surgeon and practiced from 1911 to 
1926 in Highland Park, after which time he retired 
and lived in San Antonio, Texas, where he died on 
September 10, 1938. 


Dr. Clarence B. Wasson 

Dr. Clarence B. Wasson of Bellevue passed away 
on December 6, 1938, after an illness of ten years. 
He was born in 1865 in Cuba, New York, and was 
graduated from the Rochester College and Rochester 
Seminary of Rochester, New York, and from the 
Medical Department of the University of Michigan. 
Having previously become an ordained minister, he 
decided to go through medical school to become a 
medical missionary. In 1901 he located in Bellevue, 
where he practiced medicine until 1929. During this 
period he was very active in the work of the Bap- 
tist Church, as deacon, trustee, treasurer, teacher and 
Sunday School Superintendent. On September 5, a 
beautiful memorial window of art glass in the Bap- 
tist church was dedicated to Dr. Wasson. Surviving 
him are his wife and a sister, Mrs. Lucy F. Burlin- 
game of Hinsdale, New York. 


Why Medicine Can Never Be a Trade 

“Charity is the eminent virtue of the medical pro- 
fession. Show me the garret or the cellar which its 
messengers do not penetrate ; tell me of the pesti- 
lence which its heroes have not braved in their er- 
rands of mercy; name to me the . . . practitioner 
who is not ready to be the servant of servants in 
the case of humanity . . . and whose footsteps you 
will find in the path of every haunt of striken hu- 
manity .” — Oliver Wendell Holmes. 


172 


Jour. M.S.M.S. 





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February, 1939 


173 




General News And Announcements #> 


100 Per Cent Club for 1939 

Luce County Medical Society 
Menominee County Medical Society 
Muskegon County Medical Society 
Ontonagon County Medical Society 
Tuscola County Aledical Society 

The above county medical societies have 
paid 1939 dues for 100 per cent of their mem- 
bership. Dues for 1939 are $12.00 and are 
now payable. See your County Medical So- 
ciety Secretary today and help make your 
society 100 per cent paid up for 1939. 


The sympathy of their many friends is extended 
to Dr. L. J. Gariepy and brothers and sisters in the 
death of their father which occurred in Marine 
City early in January. 

* * * 

Your Federal Income Tax report must be filed by 
March 15, 1939. For a comprehensive digest of the 
physician’s income tax, see the Journal of the 
A.M.A., January 14, 1939, page 151. 

* 5}C 

James L. Lozve, president of the Butterworth 
Hospital Board of Trustees, recently created a fel- 
lowship providing not less than $500.00 yearly for 
postgraduate study by physicians and surgeons of 
Butterworth Hospital staff. 

* * * 

President Luce has appointed Martin H. Hoff- 
mann, M.D., of Eloise, Michigan, as representative 
of the Michigan State Aledical Society to the Beard 
of the Child Guidance Center in Ingham County. 

Dr. L. S. Lipschutz was also appointed by Pres- 
ident Luce to serve as a member of the Alaternal 
Health Committee. 

* * * 

“On the Witness Stand,” a booklet which gives 
enlightening and intelligent answers on the question 
of socialized medicine, et cetera, is available — free 
to anyone who will write for same to the Executive 
Office, 2020 Olds Tower, Lansing. Your patients 
might be interested in looking through this inter- 
esting brochure; write for a supply for your wait- 
ing room. 

* * * 

The H ought on-Baraga-Keweenaw County Medical 
Society, at its annual meeting, January 3, 1939, 
elected the following officers : President, Dr. J. R. 
Kirton, Calumet ; president-elect, Dr. C. A. Cooper, 
Hancock; secretary-treasurer, Dr. Paul Sloan, Tri- 
mountain ; delegate, Dr. G. M. Waldie ; alternate, 
Dr. G. C. Stewart, Hancock; member Board of 
Ethics, Dr. A. D. Aldrich, Houghton; member of 
Council, Dr. W. T. S. Gregg, Calumet. 

* * * 

Business Is Too Good. On Sunday, January 22, 
five committees of the Alichigan State Aledical 
Society held meetings, almost simultaneously ! The 
Special Committee on Group Hospitalization met in 
Flint, at 11 a. m. ; the Advisory Committee to Wom- 
an’s Auxiliary met in Saginaw at 11 a. m. ; the 
Preventive Aledicine Committee met in Detroit at 
2 p. m. ; the Legislative Committee met in Lansing 
at 2 p. m. ; and the Committee on Scientific Work 
met in Lansing at 3 p. m. 


The Alumni Association of the Wayne Univer- 
sity College of Medicine, Detroit, is making elab- 
orate preparations for the celebration next June 
of the seventieth anniversary of the founding of 
the Wayne University College of Aledicine, and 
the fiftieth anniversary of the Alumni Associa- 
tion. Particulars of the coming celebration will 
appear each month in this Journal. 

* * * 

New county medical societies secretaries have 
been elected for 1939 as follows : 

E. B. Johnson, M.D., Allegan County 
R. C. Conybeare, M.D., Berrien County 

L. J. Hakala, M.D., Chippewa-Mackinac County 
A. W. Strom, M.D., Hillsdale County 

Paul Sloan, M.D., Houghton-Baraga-Keweenaw County 
D. Bruce Wiley, M.D., Macomb County 
R. Ostrander, M.D., Mason County 
Dale E. Thomas, M.D., Saginaw County 
The above supplements the list published in the 
January 1939 issue of The Journal. 

* * * 

Afflicted Child Commitments for month of De- 
cember, 1938: Total cases, 2,250, of which 222 were 
sent to University Hospital and 2,028 were sent 
to miscellaneous local hospitals. From Wayne Coun- 
ty, of the above, 46 went to University Hospital and 
327 to miscellaneous local hospitals, total of 373. 

Crippled Child Commitments : Total cases 227, of 
which 65 were sent to University Hospital and 16Z 
to miscellaneous hospitals. From Wayne County, 
included above, 7 were sent to University Hospital 
and 40 to local hospitals, total of 47. 

* * * 

Ten more of your friends, who displayed their 
products and services at the 1938 Detroit Convention 
last September. When you have an order, don’t 
forget your friends! 

J. B. Lippincott Company, Philadelphia, Pennsylvania 

M. & R. Dietetic Laboratories, Inc., Columbus, Ohio 
Mead Johnson & Company, Evansville, Indiana 
Medical Arts Surgical Supply Company, Grand Rapids,. 

Michigan 

Medical Case History Bureau, New York, New York 
Medical Protective Company, Wheaton, Illinois 
The Mennen Company, Newark, New Jersey 
Merck & Company, Inc., Rahway, New Jersey 
The Wm. S. Merrell Company, Cincinnati, Ohio 
The C. V. Mosby Company, St. Louis, Missouri. 

* * * 

Four solid days of good fellowship and unequalled 
postgraduate opportunity are being arranged for you 
by the Committee on Scientific Work at the Sev- 
enty-Fourth Annual Convention which will be held 
in Grand Rapids. All General Assemblies will be 
held in the Civic Auditorium; the largest technical 
exhibit in the history of the State Society will be 
housed also in the Civic Auditorium. Forty of the 
most eminent speakers of the United States and 
Canada will bring the latest information on sub- 
jects covering all branches of the practice of med- 
icine. Alark September 19, 20, 21, 22, 1939, on your 

calendar now. 

* * * 

After accidentally finding a number of unsuspected 
cases of tuberculosis in school teachers of Jackson, 
the Jackson County Aledical Society, on January 17, 
unanimously passed a motion concerning the follow- 
ing recommendation : 

“We recommend that each school teacher in Jackson 

County be required to furnish a health certificate from 
their family doctor, which certificate shall include a neg- 
ative Kahn test and either a negative Mantoux test or 
a negative report on an. x-ray of the chest, before their 
contract shall be renewed when the time for such renewal 
shall occur. The secretary, in the same motion, was in- 
structed to mail a copy of this recommendation to the 
Board of Education of the City of Jackson, the State of 

Jour. AI.S.AT.S. 


174 


GENERAL NEWS AND ANNOUNCEMENTS 


Michigan Board of Education, to the Michigan State De- 
partment of Health and to the Secretary of the Michigan 
State Medical Society.” 

* * * 

Michigan physicians contributed articles to the 
Journal of the American Medical Association re- 
; cently, as follows : “Plastic Surgery in Children : The 
i Medical and Psychologic Aspects of Deformity,” 
by Claire L. Straith, M.D., and E. Hoyt DeKleine, 
M.D., Detroit, issue of December 24 ; “Malignant 
Neoplasms of the Nasopharynx,” by I. Jerome 
Hauser, M.D., Detroit, and Durwin H. Brownell, 
M.D., Ann Arbor, issue of December 31 ; “A New 
j Interpretation of Hyperglycemia in Obese Middle 
Aged Persons,” by L. H. Newburgh, M.D., and Jer- 
; ome' W. Conn, M.D., Ann Arbor, issue of January 
7 ; and “Hypoglycemia” by Frederick A. Coller, 
M.D., and Howard C. Jackson, M.D., of Ann Arbor, 
issue of January 14. 

* * * 

The first January meeting of the Northern Mich- 
igan Medical Society was held on Thursday, Jan- 
uary 12, 1939, at the Perry Hotel, Petoskey. Dr. 
Miller was asked by President Dean Burns to in- 
troduce Henry K. Ransom, Associate Professor of 
Surgery of the University of Michigan, who read a 
paper on the Surgery of the Stomach and Duode- 
num. Following Doctor Ransom’s paper was a mo- 
tion picture showing “The Effect of Ergotison on the 
Postpartum Uterus.” 

The next order of business was a report given by 
Dr. Saltonstall on the meeting of the delegates to 
the State Medical Society held in Detroit on Jan- 
uary 8, 1939. A discussion of the report by the 
entire society followed. The meeting was adjourned 
at 10 :00 p. m. 

* * * 

In recognition of research work done in the 
field of Internal Medicine, metabolic disorders and 
cardiology, Dr. Walter M. Bartlett of Benton Har- 
bor was duly elected a Fellow of the American 
College of Physicians at the meeting of the Board 
of Regents of the College held at Philadelphia, on 
December 18, 1938. Dr. Bartlett received his cer- 
tification as a qualified specialist from the American 
Board of Internal Medicine on June 11, 1938, fol- 
lowing a four months’ course in cardiology, taken 
in various clinics on the West Coast, and has since 
served as cardiologist on the staffs of Mercy Hos- 
pital, Benton Harbor, and the St. Joseph Sanitarium, 
St. Joseph. At a recent meeting of the Medical 
Division of the General Staff of Mercy Hospital, 
Dr. Bartlett was named Chairman and Dr. R. B. 
Howard, Benton Harbor, Secretary. 

* * * 

A Course in Anatomy 

As announced in the January number of this 
Journal, a course in anatomy will be given at the 
University of Michigan from February 13 to May 
30, one afternoon and evening, each week from one 
to ten p. m., by Dr. Rollo E. McCotter. There will 
be an informal lecture the first part of the after- 
noon followed by a dissection of the part under 
discussion. A fee of twenty-five dollars is charged. 
Graduate or postgraduate credit can be arranged. 
For further information, address the Department of 
Postgraduate Medicine, University of Michigan, Ann 
Arbor, Michigan. 

* * * 

Beaumont Foundation Lectures 

The annual Beaumont Foundation Lectures un- 
der the auspices of the Wayne County Medical So- 
ciety will be held in the lecture hall of the Art 
Institute on February 20 and 21. The lecturer is 
Dr. Jesse G. M. Bullowa of New York. Dr. Bullowa 
has done pioneer work in pneumonia therapy. The 
series of lectures for 1939 are as follows : “The 

February, 1939 


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175 


GENERAL NEWS AND ANNOUNCEMENTS 



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Choice of a Remedy, with Particular Reference to 
the Pneumonias,” and “The Method and Results 
of Serum Therapy in the Pneumococcic Pneumo- 
nias.” As in former years, a cordial invitation is 
extended to every member of the Michigan State 
Medical Society to attend these lectures. 

* * * 

Women’s Cancer Movement 

One of the newest of the national health move- 
ments is the Women’s Field Army of the American 
Society for the Control of Cancer, which was or- 
ganized two years ago and at the present has ac- 
tive divisions in forty-five states. The work of the 
Women’s Field Army, carried on in collaboration 
with the local state and county medical societies, is 
largely educational; that is, the spreading of infor- 
mation regarding the nature of cancer and how to 
recognize the earliest stages. Two simple things are 
urged for every person, namely, a complete physical 
examination and knowledge of cancer danger sig- 
nals. The educational work of the Field Army is 
supplemented in some states by appropriations for 
the care of indigent cancer patients, as well as 
equipment for cancer clinics. The month of April 
has been designated Cancer Control Month, for the 
purpose of carrying on a campaign to enlist sup- 
port. “Cancer is curable. Fight cancer with knowl- 
edge,” is the ambitious slogan of this enterprising 
movement which is worthy of support. 

* * * 

The Michigan Pathological Society held its an- 
nual meeting at the University of Michigan Hos- 
pital, Ann Arbor, on December 10, 1938. 

The scientific subject of the meeting was “Pathol- 
ogy of Drugs.” Dr. O. M. Gruhzit, of Parke, Davis 
& Co., presented several interesting studies of the 
effect of drugs on experimental animals. Other 
members presented pathological material illustrating 
the effect of drugs upon the human subject. Of 
considerable interest was a case presented by Dr. 
S. E. Gould, of Eloise, demonstrating sulfanilamide 
as a cause of agranulocytic angina. Dr. C. I. Owen, 
Detroit, presented a case of mercury bichloride 
poisoning illustrating the pathological changes in the 
kidneys. Dr. Gabriel Steiner, Detroit, presented a 
case of myochrysin poisoning. Dr. C. H. Binford, 
Detroit, presented a case of carbon tetrachloride 
poisoning. Dr. Martha Madsen, Detroit, presented 
two cases of lipoid pneumonia in infants. Dr. J. H. 
Ahronheim, Jackson, presented a case of strychnine 
poisoning. Dr. D. C. Beaver, Detroit, and Dr. M. J. 
Rueger, Detroit, presented a case of hydropic de- 
generation of the kidneys induced by concentrated 
intravenous sucrose injections. In the discussion of 
Dr. Gruhzit’s material, Dr. Hartman brought out 
certain important correlations as he had observed 
them jn human and experimental pathology in cases 
suffering from anoxemia induced by fever therapy. 

The following officers were elected: President, 

Dr. O. W. Lohr; President-elect, Dr. W. L. Brosius; 
Secretary-Treasurer, Dr. D. C. Beaver; Councillor, 
Dr. O. A. Brines. 

* * * 

Physicians who have addressed county medical 

societies and lay groups during the past month or 
two : 

Wilfrid Haughey, M.D., of Battle Creek spoke to 
Kiwanis Club of Kalamazoo on February 1, on 
“Michigan’s Group Hospitalization and Medical 

Care Plan.” 

L. G. Christian, M.D., and Ralph Wadley, M.D., 
of Lansing, discussed the medical and surgical man- 
agement of diseases of the gall bladder and liver 
before the Eaton County Medical Society in Char- 
lotte on January 19. The same presentation was 

given before the St. Joseph County Medical Society 
on February 9. 


176 


Jour. M.S.M.S. 


GENERAL NEWS AND ANNOUNCEMENTS 


Harold Miller, M.D., of Lansing, addressed a 
girls’ assembly of 1,100 at Bay City Central High 
School on “Sex Hygiene’’ on January* 11. In the 
evening, Dr. Miller addressed a public meeting of 
over 1,400 at the Nurses’ Home of Mercy Hospital. 
These meetings were sponsored by the Woman’s 
Auxiliary of the Bay County Medical Society. 

F. J. Hodges, M.D., of Ann Arbor spoke before 
the Bay County Medical Society* on January* 11 on 
“Gastric Carcinoma.” 

C. E. Merritt, M.D., and W. G. Gamble, M.D., of 
Bay City addressed the Livingston County* Medical 
Society on January* 16 on the subject “The County 
Health Unit.” 

J. O. Goodsell, of the Michigan State Dental So- 
ciety*, spoke before the St. Clair Medical, Dental 
and Bar associations on January 10. A. J. Mac- 
Kenzie, M.D., spoke on behalf of the County Med- 
ical Society, and Attorney Frank Wilscn for the 
Bar Association. 

Wilfrid Haughey*, M.D., and H. F. Becker, M.D., 
of Battle Creek, spoke at Sturgis to the St. Joseph 
County Medical Society* on January* 12, on “Group 
Medical Care Plans.” 

B. R. Corbus, M.D., of Grand Rapids, President- 
Elect of the M.S.M.S., spoke to the Community 
Qub of Cedar Springs on January* 19 on Michigan’s 
Group Medical Care Plans Versus Socialized Med- 
icine. 

C. A. Stimson, M.D., of Eaton Rapids, addressed 
the Clinton County Medical Society in St. Johns 
on January 31. His subject was “Proctology.” 

Roy H. Holmes, M.D., of Muskegon, spoke to 
the Bluffton School P.T.A. on November 9 on 
“Syphilis”; to the Bluffton Community Church 
Men’s Club on December 6, and the Y’s Men’s Club 
International on December 14, on the same sub- 
ject 


County Medical Society secretaries and other of- 
ficers of the county and state medical societies at- 
tended the Secretaries’ Conference in Lansing on 
January* 15, in the number of 85. Those registering 
included Secretaries Florence Ames, M.D. ; W. H. 
Bamum, M.D. ; D. K. Barstow, M.D. ; Otto O. 
Beck, M.D. ; E. W. Blanchard, M.D. ; D. C. Bloem- 
endaal, M.D. ; Wm. M. Brace, M.D. ; J. H. Burley, 
M.D. ; C. G. Clippert, M.D. ; Thomas H. Cobb, 
M.D. ; T. S. Conover, M.D. ; R. C. Conybeare, M.D. ; 

L. W. Gerstner, M.D. ; C. L. Grant, M.D. ; L. J. 
Hakala, M.D. ; C. D. Hart M.D. ; Wilfred Haughey, 

M. D. ; H. C. Hill, M.D. ; R. J. Himmelberger, M.D. ; 
T. Y. Ho, M.D. ; B. I. Johnstone, M.D. ; W. S. Jones, 
M.D. ; C. E. Lemen, M.D. ; A. F. Litzenburger, M.D. ; 
John J. McCann, M.D. ; H. R. Mooi, M.D. ; M. R. 
Murphy, M.D. ; R. A. Ostrander, M.D. ; E. S. Par- 
menter, M.D. ; Horace Wray* Porter, M.D. ; J. W. 
Rice, M.D. ; D. R. Smith, M.D. ; A. W. Strom, M.D. ; 
Dale E. Thomas, M.D. ; J. M. Whalen, M.D. ; Thom- 
as Wilensky, M.D. ; D. Bruce Wiley, M.D. ; and A. 
L. Ziliak, M.D. 

Others present included Doctors B. R. Corbus, L. 
Femald Foster, F. T. Andrews, W. E. Barstow, 
R. H. Holmes, V. M. Moore, officers and councilors 
of the State Society*; Doctors L. M. Bogart, G. D. 
Bos, J. B. Bradley, R. M. Bradley, G. R. Bullen, L. 
G. Christian, L. W. Day, C. F. DeVries, B. H. Doug- 
las, G. F. Fisher, L. A. Frenette, S. W. Hartwell, 
T. F. Heavenrich, B. A. Holm, D. A. Jamieson, O. G. 
Johnson, L. R. Keagle, J. W. Kemper, C. S. Ken- 
nedy, E. C. Long, G. L. AIcClellan, G. M. McDow- 
ell, E. G. McGavran, A. B. McGraw, Wm. B. Mc- 
Williams, H. A. Miller, F. B. Miner, Dean W. My- 
ers, Constantine Oden, R. H. Pino, E. W. Schnoor, 
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February, 1939 


177 


GENERAL NEWS AND ANNOUNCEMENTS 


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Stimson, D. W. Thorup, L. C. Towne, Bert VanArk r 
J. D. VanSchoick, J. A. Wessinger, R. A. Wilcox. 

Also present were Senators D. Hale Brake and 
Henry F. Shea ; Representatives Dora Stockman and 
Douglas D. Tibbits ; Health Commissioner Don W. 
Gudakunst ; Dr. C. C. Young of the State Health 
Laboratories ; M. R. Kinde, M.D., of the Kellogg 
Foundation; W. S. Ramsey, M.D., Secretary of the 
Michigan Crippled Children Commission ; Miss Olive 
Sewell, R.N., Executive Secretary of the Michigan 
State Nurses Association, and Miss Anne Quigley, 
R.N.; J. O. Goodsell, D.D.S., C. J. Wright, D.D.S., 
and Executive Secretary H. C. Gerber, Jr., of the 
Michigan State Dental Society ; John A. MacLellan r 
Executive Secretary of the Michigan Conference of 
Social Work; Seth Burwell of the State Insurance 
Department ; Henry C. Black and A. E. Skaggs of 
Battle Creek ; J. A. Bechtel, Executive Secretary 
and Mr. H. R. Lipson, of the Wayne County Medical 
Society, and Executive Secretary Wm. J. Burns of 
the State Society Executive Office 

* * * 

ART TELLS HISTORY OF AMERICAN 
MEDICINE 



“Beaumont and St. Martin” 


“Beaumont and St. Martin” is the first of six 
large paintings in oil memorializing “Pioneers of 
American Medicine” which Artist Dean Cornwell 
will complete in the next few years. Others in the 
series are : Dr. Oliver Wendell Holmes, Dr. Ephraim 
McDowell, Dr. Crawford W. Long, Dr. William T. 
G. Morton, and Major Walter Reed, and one wom- 
an, Dorothea Lynde Dix, who, while not a physi- 
cian, stimulated physicians to study insanity and 
feeblemindedness. 

Arrangements to supply physicians with free, full 
color reproductions of “Beaumont and St. Mar- 
tin” without advertising, and suitable for framing, 
have been made with the owners, John Wyeth and 
Brother, 1118 Washington Street, Philadelphia. 

* ;}: * 

Little Mary Lou — Mother Dear, if there are any 
men up in Heaven why is it that we never see pic- 
tures of angels with whiskers? 

Mother Dear — Well, I guess it is because most 
men get there only by a very close shave. 

Tour. M.S.M.S. 



178 



THE DOCTOR'S LIBRARY 


THE DOCTOR’S LIBRARY 


Acknowledgement of all books received will be made in 
this column and this will be deemed by us a full com- 
pensation to those sending them. A selection will be made 
for review, as expedient. 


CANCER AND DIET. By Frederick L. Hoffman, LL.D. 

Baltimore. The Williams and Wilkins Company, 1937. 

The author, who is neither a physician nor a sci- 
entist, has been interested in the statistical and diet- 
ary aspect of cancer for years. His book, which 
contains 72 9 pages, is divided into four parts. The 
first is an interesting historical review of the de- 
velopment of cancer theories, particularly those re- 
lating to diet. The second is a study of modern diet 
compared to the diet of past generations. The third 
part, entitled “Cancer Metabolism,” reviews the liter- 
ature pertaining to food metabolism and that of 
certain organic and inorganic chemicals as well as 
enzymes, hormones and vitamins in cancer. The 
last and largest section is devoted to “Dietary 
Facts,” consisting of a mass of unreliable informa- 
tion collected by questionnaires from cancer patients. 

It is the author’s conviction that cancer is pro- 
duced by excessive nutrition and he presents what 
he believes to be the affirmative side of the argu- 
ment. His inability to evaluate the authors and ar- 
ticles he reads results in verbosity. He begins with 
his conclusions, supports his opinions by extensive 
reading and presents nothing new regarding the 
cause of cancer. Admittedly an interesting book, 
it is not highly recommended to those whose time 
for reading is limited. 


SCARLET FEVER. By George F. Dick, M.D., D.Sc., and 
Gladys Henry Dick, M.D., Dc.Sc., 149 pp., $2.00 post- 
paid. Chicago: The Year Book Publishers, 1938. 

The authors of this treatise have long been recog- 
nized as eminent authorities on the skin test for sus- 
ceptibility to scarlet fever. In this book they have 
utilized their extensive experience in presenting a 
complete consideration of the subject. In the chap- 
ters devoted to the clinical aspects of the disease 
there are comprehensive discussions of the varieties 
of scarlet fever, complications, diagnosis and prog- 
nosis, treatment, skin tests, and of prophylaxis. The 
considerations of the preparation of scarlet fever 
toxin, specificity of the hemolytic streptococci, 
allergy, antibacterial immunity, local immunity, and 
oral immunity complete the story by presenting the 
laboratory aspects of the disease. The nice arrange- 
ment of these topics makes their data quickly avail- 
able, The colored plates of the early scarlatinal 
rash, Pastia’s lines, the strawberry and the rasp- 
berry tongue, the blanching test, the skin reactions 
and their interpretations, and of the specificity tests 
are unexcelled. 

This monograph is a very practical work, because 
it is so detailed and at the same time so concise. 
The direct and lucid style with which these authors 
translate their wealth of experience into a text, rec- 
ommends this book to whoever is concerned with 
any aspect of scarlet fever. 


CLASSIFIED ADVERTISING 

POSITION WANTED — By expert stenographer. 
Can furnish best of references. Willing to accept 
position in any part of the state. Write C.P.A., 
2020 Olds Tower, Lansing, Michigan. 

February, 1939 


Among Our Contributors 


Dr. Franklin G. Ebaugh is a graduate of Johns 
Hopkins University, class of 1919. He is part 
time Director of the Division of Psychiatric Ed- 
ucation, National Committee for Mental Hygiene 
and a member of the American Board of Psy- 
chiatry and Neurology and the Advisory Board 
of Medical Specialties. 

Jji 

Dr. John J. Engelfried has the following de- 
grees from the University of Michigan: B.S., 
M.S.P.H., and D.P.H. He is an instructor in the 
Department of Pediatrics and Infant Diseases 
and has been associated with Dr. Cowie in re- 
search work for three years. 

5jC 3j« 5&C 

Dr. E. R. Schmidt received the degree of A.B. 
in 1913 at Wisconsin, and M.D. in 1916 at Wash- 
ington. He was first Lieutenant, M.R.C., 1917-18; 
Captain, M.C., U.S.A., 1918-19; Commanding Of- 
ficer, U.S.A. Base Hospital No. 11, in 1919. From 

1921- 22, he was Exchange Assistant at the 
Maria Hospital, Stockholm, Sweden; and from 

1922- 23, Exchange Assistant, at the Stadtische 
Krankenhaus, Frankfurt-am-Main, Germany. Dr. 
Schmidt was a member and governor of the 
American College of Surgeons, is a member of 
the Western Surgical Association; German Surg- 
ical Congress; Wisconsin State Medical Society, 
and the American Surgical Association. He is a 
member of Nu Sigma Nu medical fraternity. Dr. 
Schmidt has been Professor of Surgery at the 
University of Wisconsin Medical School since 
1926, as well as surgeon at the Wisconsin Gen- 
eral Hospital. 

Jfc 3{C 5{C 

Dr. Stanley J. Seeger was graduated from the 
Northwestern University Medical School in 1911, 
and received the degree of M.S. from Marquette 
University in 1936. He is a past-president of the 
Milwaukee County Medical Society, past-pres- 
ident of the Wisconsin State Medical Society, 
and past-president of the Alumni Association of 
the Mayo Foundation. At the present, Dr. See- 
ger is chief of staff of the Columbia Hospital 
and the Milwaukee Children’s Hospital, and 
chairman of the Council on Industrial Health of 
the American Medical Association. 

* * * 

Dr. Donald S. Smith graduated from the Uni- 
versity of Michigan in 1934. He served his in- 
terneship at the University Hospital, Ann Arbor, 
and was Instructor in Internal Medicine there in 
1936-38. He is an associate member of the Amer- 
ican College of Physicians and Consultant In- 
ternist at Pontiac State Hospital. His practice 
is limited to internal medicine. 

Jfc ^ 

Dr. Kellogg Speed is a clinical professor of 
surgery at Rush Medical College, Chicago, and 
attending surgeon to the Presbyterian Hospital, 
Chicago. Dr. Speed is author of the textbook, 
“Fractures and Dislocations.” 


179 


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MATERNAL HEALTH 

From the Committee on Maternal Welfare of the 
Michigan State Medical Society 

Maternal health may be defined as an achievement 
wherein women desirous of parenthood are able to 
conceive, give birth to healthy children, in reason- 
able numbers, and accomplish the same without im- 
pairment of mental or physical efficiency. 

It is obvious that this desideratum can rarely be 
an accomplished fact, without the aid of intelligent 
obstetric supervision and management. 

Maternal health presupposes a satisfactory heredi- 
tary and environment influence, and proper super- 
vision of the newborn which should be continued 
throughout the stages of childhood and adolescence, 
and throughout the mating period. 

Appropriate antenuptial examination and advice 
should be given and at marriage every woman 
should avail herself of contraceptive information 
and treatment. 

Marriage should be followed by supervision of 
the wife from the standpoint of maternal health and 
this should be continued throughout the whole re- 
productive life. 

This broad conception of maternal health involves 
serious responsibilities upon the medical profession 
and upon the public. 

It has been, and continues to be, the purpose of 
the Maternal Health Committee of this state to 
exert every effort to assist the doctors in the state 
to render good obstetric service, and to instruct the 
people to appreciate it. 

Michigan has taken a foremost position in its 
Maternal Health Program. 

Every County Medical Society in the state has a 
Committee on Maternal Health, and its duties and 
functions are, to become interested in a practical 
way, in all maternal health problems in their own 
county, and to cooperate with the state committee in 
its effort to help give the expectant mothers in 
Michigan an increasingly better service. 

President Luce has increased the membership of 
our committee which now consists of six obste- 
tricians, three pediatricians, and one psychiatrist. 
This broadens our duties and increases our responsi- 
bilities. 

Our Committee needs, and earnestly solicits, the 
aid of all physicians in the state who do obstetric 
work, and it is particularly anxious to see every 
County Maternal Health Committee assuming re- 
sponsibility toward solving local maternal health 
problems, and these problems are present in every 
community. 

Alexander M. Campbell, M.D. 
Chairman, Committee on Mater- 
nal Health, Michigan State Med- 
ical Society. 


SCIENTIFIC COMMITTEE 


CHICAGO 

TUMOR 

INSTITUTE 


21 WEST ELM ST. 
PHONE DEL. 5600 


Max Cutler, M.D., Chairman Arthur H. Compton, Ph.D. 

Sir G. Lenthal Cheatle, F.R.C.S. Ludvig Hektoen, M.D. 

Henri Coutard, M.D. 

The Chicago Tumor Institute offers consultation service to phy- 
sicians and radiation facilities to patients suffering from neoplas- 
tic diseases. Graduate instruction in radio-therapy is offered to 
qualified physicians. 

The Radiation Equipment Includes: 

One 220 k.v. x-ray apparatus 
One 400 k.v. x-ray apparatus 
One 500 k.v. x-ray apparatus 
One 10 gram radium bomb 


180 


Jour. M.S.M.S. 


THE JOURNAL 

OF THE 

Michigan State Medical Society 


ISS 

UED 

MONTHLY UNDER THE 

DIRECTION 

OF THE COUNCIL 

Vol. 

38 

MARCH, 

1939 

No. 3 


SOLITARY CYST OF THE SPLEEN 
Report of a Case 

F. T. ANDREWS, M.D., Kalamazoo, Michigan 
and 

R. S. HARTER, M.D., Schoolcraft, Michigan 

In discussing pathologic changes in the spleen, the writer is impressed by our meager 
knowledge of the physiological functions of this organ as well as the diseases which are 
primarily of the spleen. The reporting of a single case is justified only by its rarity for 
an intensive study of the literature brings to light less than one hundred cases of solitary 
cyst of the spleen. It may be of interest that a case was reported by Dr. Harold K. 
Shawan of Detroit, which together with this report constitutes two from the State of 
Michigan. Two cases have been reported in Kentucky. The remainder are scattered over 
the entire world. 

According to Aristotle, the spleen in 
Grecian runners was removed for prolapse 
in order that their speed might be increased. 

This was done by incision through the left 
groin. Andral, in 1829, in an autopsy found 
the first reported case of cyst of the spleen ; 
nearly fifty years lapsed before Pean, in 
1867, removed the first cystic tumor of the 
spleen. 

The classification of large non-parasitic 
splenic cysts (Boyd) is as follows: hydat- 
id, dermoid, simple, hemorrhagic and se- 
rous. This classification is by structure and 
pathology and not according to cause. 

Embryologically, the parenchyma of the 
spleen is entirely mesodermal in origin 
(Muller) and the capsule and trabeculae are 
mesothelial in origin, as are the sexual 
glands. This may give rise to the ancient 
idea that the splenectomized woman is un- 
able to become pregnant which has been 
disproved in two cases, one patient who 
was delivered of a living child and at the 
time of writing was eight months pregnant 
for the second child. The other case was 


delivered of a living and healthy child. 
The fact that the spleen becomes engorged 
during menstruation may account for the 
above mentioned fallacy. 

The causes of splenic cysts are many and 
varied. Traumatism by direct violence 
seems the most probable. Lymphatic dis- 
turbance is another. Because in its jour- 
ney through the lobules of the spleen, the 
splenic artery accumulates considerable lym- 
phoid tissue within its adventitia, whereby 
it causes lymphatic disturbance and the 
spleen undergoes polycystic degeneration, 
we may therefore have a socalled wander- 
ing spleen with torsion of the pedicle, in- 
farction, or thrombosis of the small vessels, 
resulting in hematic cysts; or, there may 
be a placement of embryonic tissue which, 
lodging in the spleen, may become cystic 
and thus form a true dermoid cyst. 

The occurrence of this type of tumor is 
most frequent in women to about sixty- 
five per cent. In forty-seven cases occur- 
ring in females, the ages ran between 


March. 1939 


201 


SOLITARY CYST OF THE SPLEEN— ANDREWS AND HARTER 


twenty and forty years, and ten occurred 
associated with pregnancy. 

Diagnosis of this condition is usually 
confirmed by Roentgen ray, following the 
finding of the mass in the abdomen. The 
symptoms are most misleading. They may 
simulate those of pathological changes in 
every portion of the body by reason of me- 
chanical pressure upon some organ connect- 
ed with the abdominal cavity. The most 
prominent symptom is that of painful 
weight in the abdomen. 

Respiratory changes from the upward 
growth produce pressure upon the dia- 
phragm and cause pleuritic rubs, crepita- 
tion and often effusion, which might easily 
be mistaken for pleurisy with effusion. The 
stomach and pancreas may be involved to 
the extent of producing symptoms sugges- 
tive of carcinoma and ulcer of these organs. 
The kidney and bladder disturbances enter 
the picture with frequent micturition, neph- 
ritic changes and attacks of pain, which 
might be erroneously diagnosed as urinary 
calculus or Dietle’s crisis. Pelvic organ 
manifestations are numerous. Circulatory 
upsets may be manifest in heart displace- 
ments, edema of the lower extremities and 
abdominal effusion caused by pressure on 
the inferior vena cava or left iliac vein, 
cirrhosis of the left lobe of the liver. 

The treatment is obviously surgical, 
though medicine has been used. Large 
doses of iodine have been given, puncture 
by trocar and the aspiration of fluid, and 
injection of the capsule with three per cent 
phenol with caustic soda to remove the 
eschar of its envelope. Electro-puncture 
has also been employed. Cysts have been 
opened and the contents drained and the 
borders of the cysts sutured to the laparot- 
omy wound. Some surgeons advise the re- 
moval of the cystic spleen through the pos- 
terior route, but recent text books favor 
the anterior incision. 

The blood supply to the spleen is from 
the splenic artery, a branch of the celiac 
artery. This artery is remarkable not only 
for its large size in proportion to the amount 
of tissue which it supplies, but for the 
thickness of its walls. Thus the surgeon 
in splenectomy should be exceedingly care- 
ful to avoid premature opening or division 
of the large vessels contained in the gas- 
tro-splenic ligament and the spleno-renal 
ligament, because of the distortion of the re- 


lationship of these vessels in the cystic 
growth, flooding of the operative field with 
blood may occur. Once these vessels are 
lost, it is exceedingly difficult to pick them 
up, particularly the splenic vein. 

The formation of adhesions to various 
other organs, namely, the stomach, pan- 
creas, colon, and kidneys, should be borne 
in mind and separation and ligation should 
be attended to early and carefully. 

The authors wish to stress a part of the 
operation which has its attendant danger in 
the recovery of the patient. It is not par- 
ticularly difficult to visualize a great gaping 
void, which has been created by the re- 
moval of this large mass, into which drop 
the displaced organs, the stomach and colon. 
The patient displays symptoms of obstruc- 
tion and acute dilatation of the stomach 
with its attendant danger. This happened 
in our case and was cause for alarm for 
about two days. 

Report of Case 

Miss B., aged thirty-nine years, a laboratory work- 
er, consulted us for abdominal pains, weakness, 
nervousness and loss of weight. She complained 
of soreness in the stomach and bowels which was 
worse when she lay down than when up and about. 
She had lost eight pounds in the last two weeks. 
She reported a “bad spell” last fall that lasted 
about six weeks. Her present trouble began three 
weeks before coming to our office. The abdominal 
pains, which came on suddenly and left suddenly, 
were sharp and cramp-like in character. Her 
bowels were regular. She had more or less nausea 
but did not vomit. Apparently the pain was not 
related to eating. Both arms and her right leg 
were numb a good deal of the time. She com- 
plained a good deal of gas in the stomach and 
bowels. The pain was not related to movements 
of gas. Breathing seemed to be painful. The 
patient did not sleep well and had not slept well 
for two years. She was hard of hearing which 
had been coming on for six years or more. Her 
deafness was worse during her nervous spells. Apart 
from mumps and measles, she had been well until 
her present illness. 

About three years before seen by us, she was 
struck in the abdomen by the wheel of a car, which 
was stopped suddenly. She did not attach any im- 
portance to this injury at the time as it did not 
disable her. 

The clinical laboratory examination revealed the 
following : hemoglobin — 75 per cent, red cells — 

4,160,000, white cells — 6,000, lymphocytes — 40, neu- 
trophiles — 60; Schilling — 0-0-20-40. The Kahn test 
was negative and urinary examination revealed 
normal urine. 

The x-ray report is as follows : 

“Chest : Stereoscopic films were made of the 

chest in the postero-anterior direction with the pa- 
tient erect. On these films one sees rather indefinite- 
ly a circular, linear shadow just below the left 
diaphragm. The diaphragm moved normally and 
there is no special elevation of the diaphragm. The 
heart and lung fields appear quite normal. 

Tour. M.S.M.S. 


202 


SOLITARY CYST OF THE SPLEEN— ANDREWS AND HARTER 


“Abdomen: ,A single film made of the abdomen 
shows the circular, linear shadow in the upper left 
abdomen. No other abnormality is seen. 

“On this film the outline of the left kidney can 
be seen, apparently quite separate from the shadow 
seen above. 

“Detail studies were then made of the peculiar 
shadow seen in the upper left abdomen. A single 
film was made with the patient supine. One sees a 
round shadow of apparently a cystic mass below the 
left diaphragm. There is considerable calcification 
scattered throughout the walls of the cyst. With 
the patient in expiration, the left diaphragm is 
very slightly higher than the right. 

“The patient was then fluoroscoped carefully. The 
cystic mass could be seen. The diaphragm moved 
normally. 

“The .patient was then given barium by mouth 
and observed under the fluoroscope. It was seen at 
once that the mass in the upper left abdomen oc- 
cupies almost all the space from the lateral chest 
wall to the spine. The upper end of the esophagus 
is displaced somewhat toward the right. The fun- 
dus of the stomach is displaced downward and for- 
ward, the cystic mass being posterior. Films were 
then made in the prone, supine and upright posi- 
tions, showing the mass in the upper left abdomen. 
This mass is almost circular, about 18 cm. in dia- 
meter. The kidney appears to be displaced down- 
ward. One can almost identify the spleen lying be- 
low the mass. 

The physical examination revealed a patient, un- 
derweight and the asthenic type. The average 
weight for the last five years was 112 pounds. 
Her present weight is 101 pounds. The blood pres- 
sure is systolic 110, diastolic 70. Apparently there 
is some thickening of the ear drums. The physical 
examination was otherwise negative, excepting the 
enlarged mass which may be palpated in the upper 
left abdominal quadrant. The mass was smooth 
and movable, yet it was difficult to determine its 
attachment. 

The patient was operated upon under ether 
anesthesia. The abdomen was opened with a left 
rectus incision from the intercostal angle of the ribs 
with an incision about 12 cm. in length. Upon 
opening the abdominal cavity, the shiny, glistening 
mass was observed. Numerous small adhesions 
to the various organs were noted and freed, and 
the cyst was delivered. The pedicle of the spleen 
with gastro-splenic ligament and renal splenic liga- 
ment were clamped and divided with double liga- 
tures around stumps of both ligaments, and tumor 
amputated. The abdominal wall closed without 
drainage. 

The patient recovered from anesthesia and opera- 
tion in excellent condition. She ran a temperature 
of 101 degrees on the second day which subsided 
to normal on the sixth. On the fifth post-operative 
day, she developed alarming symptoms of abdominal 
distention, convulsive movement of the upper por- 
tion of the body, and extremities; she was irrational 
at times, and looked very ill. After consultation, 
an x-ray examination revealed a marked dilation 
of the stomach with gas. A loop of bowel was seen 
on the right side of the abdomen bending to cross 
the mid-line of the fourth lumbar vertebra. The 
bowel loop was likely the colon, but the examiner 
could not be sure of this. 

An x-ray examination of the abdomen, a day 
later, showed much less gas in the stomach. An 
other x-ray examination of the abdomen made after 
the patient had been given a small amount of 
barium per rectum, showed the colon normally out- 
lined. The position of the transverse colon corres- 

March, 1939 


ponded fairly well to the position of the gas dis- 
tended loop of bowel described. In this film, there 
was no evidence of gas distended bowel. 

The following after treatment was instituted : 
A Levine tube was inserted into the stomach and 
gastric lavage completed with instillation of mag- 
nesium sulphate, saturated solution 30 c.c., and hot 
stupes were applied to the abdomen ; intravenous 
five per cent glucose 2,000 c.c. in saline was given. 



Solitary cyst of the spleen. 


Nine days after the operation, the patient was 
much improved. The bowel movements had be- 
come normal and vomiting had ceased after the sec- 
ond gastric lavage. There were no irrational or con- 
vulsive movements. The patient went on to normal 
convalescence and was discharged from the hospital 
on the sixteenth day with the operation wound 
completely healed and in excellent condition. She 
was seen from time to time when she had minor 
complaints of vague pains, first on the left side and 
then over the lower area on the right side. On 
December 1, 1938, she felt that she had fully re- 
covered; she had no pain or abdominal distress 
and felt better than she had in ten years. 

The pathology report by Dr. H. R. Prentice was 
as follows : “Gross examination ; Ovoid specimen 

about 15x13x10.5 cm. consisting of a yellowish, 
smooth cyst, partly encapsulated by a rim of splenic 
tissue along one side, about 9 cm. long, 2.5 cm. 
across and 1.5 cm. thick. Weight of whole speci- 
men about 2.5 lbs. The broad pedicle of splenic 
tissue described has been cut across. 

“There is a plaque of calcium on the free side, 
about 13x7 cm. and other calcified plaques scattered 
through the wall. The lining is yellowish white 
with mushy brownish-yellow material adhering to 
it and there are a few calcified plaques extending 
into the lumen. The contents are caramel colored 
turbid fluid full of glistening flecks of cholesterol. 

“There is a separate specimen from the tip of the 
spleen about 5x3x1. 5 cm. 

“Microscopic diagnosis : The splenic tissue is 

normal. No epithelium is to be found in the cyst 
lining. The wall merges with the fibrous capsule 
of the spleen. This origin can be clearly seen in 
some areas where the hypertrophic peri-vascular 
trabeculae join in the capsule. There is extensive 
atheromatous change throughout the wall and diffuse 
calcification of the lining.” 

Bibliography 

1. Benton, Roy W. : Large Cyst of Spleen. 

2. Cuff, Cyril C. H.; and Gosden Minnie: A case of non- 

parasitic cyst of spleen. Translation of the Royal So- 
ciety of Tropical Medicine and Hygiene, (Nov.) 1933. 

3. Cruickshank, M. M.: Cyst of the spleen. Indian Med- 

ical Gazette, (Nov.) 1935. 


203 


GLOMUS TUMOR— MEYERS 


4. Lewis, Dean: Practice of Surgery. 

5. Novak, Emil: Surg. Gynec. and Obstet. ; 45, 586, 

389 (Nov. 27). 

6. Shawan, Harold K. : Epidermoid cyst of spleen. Arch. 

Surg., 27; 63, 74, (July) 1933. 

7. Starr, Frederick N. G. : Intracapsular rupture blood 

cyst of spleen. Ann. Surg., (Nov.) 1933. 


8. Sanders, A. W. : British Jour. Surg., (July) 1928. 

9. Tilton, Benjamin T. : Non-parasitic cyst of spleen. 

Amer. Jour. Surg., (May) 1933. 

10. Wallace, Frank L. : Unilocular cysts of spleen. Ann. 

Surg., 360, (March 27). 

11. Wladyslaw, Dobrzanieske: Multiple cyst of spleen pro- 

duced by infarct. Ann. Surg., (July) 1930. 


GLOMUS TUMOR* 

A Report of Four Cases 
MAURICE P. MEYERS, M.D. 

DETROIT, MICHIGAN 


The finding of four patients with glomus tumor during the past year calls attention to 
this frequent but little known neuro-vascular neoplasm of the extremity. This small 
tumor is a definite pathological entity and exhibits distinctive clinical findings character- 
ized mainly by severe pain and tenderness. Operation results almost uniformly in cure. 


Symptomatology 

Pain is the most constant feature of a glomus tumor. 


It occurs in the small area at 


the site of the tumor, usually in the finger, 
ing, burning, piercing or bursting. It us- 
ually grows progressively worse. It comes 
in paroxysms of several minutes to several 
hours. It may be only local, but usually 
also radiates for long distances up the arm, 
to the neck and even the thorax. Par- 
oxysms are initiated by change in weather, 
exposure to cold or by pressure. The local 
tumor area, on touch, may act like a “trig- 
ger” zone in tic douleureux. Patients often 
go to extremes to protect themselves from 
the pressure of clothes or contact with cold. 
However, one of our patients complained of 
aggravation of pain on exposure to heat. 

The tumor is only found in the extremity, 
and most commonly in the finger. It may 
be neither visible nor palpable, as was true 
of two of our cases. Then there will be a 
tiny point of exquisite tenderness which can 
be located by careful mapping with the point 
of a pencil. When a tumor is visible it ap- 
pears as a bluish, purplish or reddish dis- 
coloration of the skin. It usually attains a 
size of 3-5 mm. in diameter but sometimes 
may grow as large as 3 cm. in diameter. It 
may elevate the skin slightly. The location 
of the tumor is most frequently beneath the 
nail. Then the discoloration may be seen 
through it. The tumor may hollow out a 
cavitv in the phalanx underneath, or thin 
the overlying nail. Some patients have ob- 
tained temporary relief by shaving the nail 
away from the growth, or by drilling a hole 
in the nail as occurred in one of our cases. 

Stout has observed that a relatively 


This pain is described as exquisite, agoniz- 


*Presented for publication, April 13, 1938. 

204 


high proportion of these tumors develop in 
Jews, a people known to lie prone to dis- 
turbances in the sympathetic nervous sys- 
tem in the extremities. All our four pa- 
tients were Jewish. The tumor may occur 
at the site of previous trauma. Of sixty- 
one cases reviewed by Stout forty-five were 
in the upper extremity and sixteen were in 
the lower. Of these, twenty-seven were 
sub-ungual, but only one under the toe-nail, 
the remaining twenty-six under the finger 
nail. Three of our cases occurred in the 
fingers, the fourth on the thigh. The age 
of onset has ranged from childhood to old 
age. Cases with multiple tumors have been 
recorded by Adair and others. In all, about 
100 cases have been reported to date. 

Case Reports 

Case 1. — Mrs. E. P., a Jewish housewife, aged 
fifty-four, was seen March 2, 1937 by Dr. H. C. 
Saltzstein with the complaint of a painful tumor of 
the posterior surface of the right lower thigh of 
three years’ duration. It had been removed two 
years ago but recurred six months later as a red- 
dened nodule. One year ago, another physician in- 
jected the area on three or four occasions with 
a (sclerosing?) solution. Since then, an aching pain 
has been present at the site of the tumor which is 
very sensitive to touch even by her clothes and bed 
sheets. 

Examination of the posterior surface of the right 
lower thigh revealed an oval scar, one by one and 
one-half inches, with an irregular surface and a 
central raised nodule, one-quarter inch in diameter. 
This nodule was exquisitely tender even to very 
light touch. It showed no external color change 
from that of the normal skin. Tn view of the ex- 
quisite tenderness a clinical diagnosis of glomus tu- 
mor was made. 

Operation was performed under local anesthesia, 

Tour. M.S.M.S. 


GLOMUS TUMOR— MEYERS 


the area of scar being entirely excised. Even in by circular injection surrounding the base of the 

preparing the skin for operation, the patient com- right middle finger with a rubber band constrictor to 

plained bitterly of the pain brought on by the light control bleeding while exploring for the tumor. Two 

rubbing. The specimen on cross section through the longitudinal lateral incisions were made up from the 

middle of the raised nodule showed it to be a tumor nail edges so the eponychial flap could be lifted up 



Fig. 1. Case 1. Glomus tumor just under epidermis of 
thigh. Shows encapsulation (magnification, 10). 

of rose red color with the appearance of great vas- 
cularity. 

Microscopic* examination showed an encapsulated 
glomus tumor under the epidermis consisting of a 
mass of typical large glomus cells in which were 
many vascular channels (Fig. 1). 

The pain was immediately relieved and a check- 
up one year later showed no recurrence of the tu- 
mor with complete relief of symptoms. 

Case 2 . — Miss F. D., a Jewish stenographer, aged 
thirty-seven, was referred by Dr. L. Segar on Oc- 
tober 18, 1937, with the complaint that for five years 
she suffered severe pain in the cuticle of the right 
middle finger which travelled up the hand and even 
to the elbow or shoulder if struck. The pain was 
brought on by change in weather, immersion in cold 
water, exposure to cold air, pressure on the finger 
or by being struck. Relief was obtained by warm- 
ing the hand. The patient had been comfortable only 
in the summer for several weeks at a time. She 
had never suffered an injury to the finger and had 
never noticed any color change. An x-ray of the 
finger was taken two years ago by another physician 
who reported it to be normal. 

Examination of the right middle finger showed 
no external change. However, there was an ex- 
quisitely tender spot in the mid-line of the epo- 
nychium about 3 mm. in diameter. Pressure on the 
nail was not painful. The temperature and color 
of this finger as well as the rest of the fingers 
was normal. The radial pulses were normally pal- 
pable. A review of the x-ray films showed a little 
cupping of the dorsal surface of the distal phalanx 
of the right middle finger as compared with the 
left side (Fig. 2). A clinical diagnosis of glomus 
tumor was made in view of the history and findings. 

Operation was carried out under local anesthesia 


*The pathologic diagnoses of all cases were made by 
fir. P. F. Morse, Pathologist, Harper Hospital, Detroit. 



Fig. 2. Case 2. Roentgenograms. Comparison of terminal 
phalanx of involved right middle finger (above) with cor- 
responding one of the other hand. Arrow points to the 
cupping of the dorsal aspect of the phalanx due to pressure 
from glomus tumor under the root of nail. 



Fig. 3. Case 2. Glomus tumor with endothelial-lined blood 
vessel surrounded by characteristic glomus cells. Area of 
myxomatous degeneration in right lower portion of .field 
(magnification, 900). 

from the base of the nail. As nothing abnormal 
was seen, the proximal half of the nail was ex- 
cised revealing a pure white nail matrix (blood 
supply constricted by rubber band). Incision through 
the mid-line of the matrix allowed a soft white 
tumor, three millimeters in diameter, to “pop up’’ 
into the w’ound as if it had been held under tension 
between the matrix and the phalanx. The tumor 
was carefully 7 excised exposing the bony phalanx 
upon which it rested. The eponychial flap was then 
resutured in place over the cavity left by’ the ex- 
cised tumor. 

Microscopic examination revealed an encapsulated 


205 


March, 1939 


GLOMUS TUMOR— MEYERS 


mass of glomus cells with few vascular channels. 
Myxomatous changes were present in several areas. 
The diagnosis of glomus hemangioma with myxo- 
matous changes was made (Fig. 3). 

There was complete relief of pain immediately 



Fig. 4. Popoff’s Conception of the Digital Glomus: “Dia- 
grammatic presentation of vascular arrangement and the 
glomus, as found in the ventral surface of the digit. It 
shows: (1) all the zones of the skin, including that occupied 
by the glomic apparatus; (2) the afferent artery of the 
glomus; (3) the coiled type of Sucquet-Hoyer canal, charac- 
terized by a thick wall; (4) the efferent part of the Sucquet- 
Hoyer canal, entering the primary collecting vein, with the 
latter appearing as a long wide ruffle encircling the glomus; 
(5) the relation of the primary collecting vein to other 
veins; (6) the system of preglomic arterioles supplying all 
the constituents of the glomus and emptying into the pri- 
mary collecting vein, and (7) division of the periarterial 
nerve trunks, with branches going to the glomus. This dia- 
gram serves to explain arteriovenous and trophic disturb- 
ances caused by functional disability and organic destruction 
of either glomus or one of its constituents.” (Copied from 
Popoff.) 

and the patient went back to her office to work 
the next day. She was able to use a pencil against 
this finger one week later. A check-up after six 
months found the patient to have enjoyed continual 
relief from pain even during the cold months of 
winter since operation. 

Case 3 . — Miss M. A., a Jewish stenographer, aged 
twenty-seven, was seen December 3, 1937, with the 
complaint of pain in the right fourth finger of ten 
years’ duration. She had been unable to typewrite 
for the past three years on account of a very 
small sensitive spot on the palmar surface of the 
finger end. Writing with a pencil was impossible 
last summer. The pain had been constant in the 
summer; intermittent in the winter. It varied in 
character, at times being sharp and at others a dull 
ache. Relief from pain was obtained by allowing 
cold water to run over the finger or by squeezing 
the finger proximal to the sensitive spot (“stopping 
the circulation,” she said). Pain was brought on 
or made worse by striking the sensitive spot with 
anything, such as a bar of soap or a wash cloth. 
This gave a “terrible shock.” The pain radiated up 
the forearm when severe, and spread to the other 
fingers as well. It was not influenced by impending 
change of weather, but was believed to be worse 
during her menstrual periods in the summer. The 
patient blushed easily and stated that she perspired 
freely in the summer. 

Examination revealed a stout, fair-haired, young 
adult woman whose skin was fine in texture, moist 
and warm. Perspiration of the hands started imme- 
diately after the patient held them up for inspection. 


Special attention was then given to the right fourth 
finger. There was no swelling, no tumor palpable, 
and no color change. There was, however, an ex- 
quisitely tender small area three millimeters diam- 
eter, just mesial and proximal to the central whorl 
of the palmar skin of the finger end. A clinical 
diagnosis of glomus tumor was made. 

Operation was carried out under local anesthesia 
by circular injection surrounding the middle phalanx 
of the right fourth finger with a rubber band con- 
strictor around the base of the finger. A longi- 
tudinal incision, one cm. in length, into the antero- 
medial aspect of the palmar surface of the finger 
end was made with its center over the tender area. 
A small tumor was found deeply in the fatty tissue 
on the palmar aspect of the distal phalanx. It 
was reddish-purple in color, encapsulated, kidney- 
shaped and measured 5x3x2 mm. It was excised 
and the wound closed. 

Microscopic examination of the tumor showed 
an encapsulated mass of glomus cells with fibrous 
septa extending in from the periphery. Vascular 
channels were present. In addition, nerve sheath 
cells of the typical wavy type and collagen fibres 
were also demonstrated. The diagnosis of glomus 
hemangioma was made. 

The patient has had relief of pain during the five 
months since the removal of the tumor with no 
evidence of recurrence. 

Case 4. — Mr. W. A., a Jewish attorney, aged thirty- 
five, was first seen in December, 1936 with the 
complaint of pain and discoloration in small area 
under the nail of the right fourth finger of ten 
years’ duration. The pain had become progressively 
worse since the onset. It radiated up to the knuckle 
usually and was excruciating in cold weather. It 
has been brought on by use of cold water to wash 
the hands, by impending change of weather to rain, 
snow or dampness when it has radiated up the arm 
and rarely even to the shoulder, by striking the nail 
accidentally which almost “knocks him out” and by 
buffing the nail in manicure. The discoloration has 
increased from pin-head size when first noted to 
three times that size. There were no vasomotor 
phenomena such as blanching, reddening or sweat- 
ing. Four years ago he prevailed upon a dentist to 
drill a hole in the nail over the discoloration. They 
came upon a “sac” but did not remove it. No relief 
was obtained with this procedure. 

On examining the right fourth finger a purplish 
discoloration, 2x5 mm., under the nail was seen 
and found to be exquisitely tender to pressure. A 
clinical diagnosis of glomus tumor was made. 

Case 4 was the most typical case of the 
group clinically, and the patient was advised 
to have this lesion removed. However, 
he has not yet submitted himself for opera- 
tion. 

The Normal Digital Glomus 

Masson, in studying two small tumors 
removed by his colleague, Barre, discovered 
the digital glomus in the peripheral vascular 
system. This structure, a coiled tuft of 
blood vessels occurring normally in great 
numbers in the extremities, is an arterio- 
venous anastomosis. Popoff, in 1934, dem- 
onstrated degenerative changes in the digi- 
tal glomus in both diabetic and senile ar- 

Jour. M.S.M.S. 


206 


GLOMUS TUMOR— MEYERS 


terio-sclerosis. He elaborated (Fig. 4) up- 
on Masson’s description of the digital glo- 
mus, describing it as consisting of ( 1 ) an af- 
ferent artery with cushion-like endothelio- 
muscular elevations directing the flow of 
blood through it; (2) a Sucquet-Hoyer 
canal, or arterio-venous anastomosis prop- 
er, which is coiled and has a thick wall 
lined by two or three rows of large endo- 
thelioid cells, surrounded by smooth muscle 
cells amidst which are the large epithelioid 
(glomus) cells of Masson; (3) the ef- 
ferent part of the Sucquet-Hoyer canal 
enters the primary collecting vein which 
appears as a long, wide ruffle encircling 
the glomus; (4) a system of pre-glomic ar- 
terioles supplying all the constituents of the 
glomus and emptying into the primary col- 
lecting veins; (5) a division of the peri- 
arterial nerve trunks with branches going to 
the glomus; (6) a neuro-reticular zone of 
collagenous fibres and non-myelinated nerve 
fibrils around the canal (the so-called clear 
zone or expansion zone) ; and (7) the out- 
ter layer of lamellated collagenous tissue 
which appears as a long wide ruffle encircling 
structures of the cutis. 

The digital glomi lie in the deep layers 
of the skin and their afferent arteries come 
off parallel to the surface from the skin ves- 
sels. The diameter of the digital glomus 
varies from 60 to 220 microns, the smaller 
ones being found in the nail beds. They are 
most numerous here. They occur mostly on 
the ventral surfaces of the hands and feet 
and in the nail beds, but probably also to a 
less extent throughout all the extremities. 
They vary in number from about 100 to 
600 per square centimeter of surface. 

The digital glomus is under the control 
of the vasomotor nerves. It serves to rap- 
idly divert the flow of blood from the ar- 
tery directly into the veins. Its most im- 
portant function is the regulation of body 
temperature (Sir Thomas Lewis). This it 
does by opening or closing to increase or 
decrease dispersion of heat. It also serves 
to maintain or raise the temperature of the 
digits when exposed to cold — by diverting 
blood through the anastomotic vessels which 
have a highly developed surface area. The 
glomus also functions to relieve peripheral 
arterial pressure by diverting blood through 
anastomotic by-passages. 

From the foregoing it will be seen that 
March, 1939 


the behaviour of the digital glomus in 
health and disease may well be a key to 
progress in the study of peripheral vascular 
disease and hypertension. 

Pathology of Glomus Tumors 

Usually no larger than a grain of rice, 
this is a minute benign tumor with major 
symptoms. Stout, in 1935, gave a detailed 
historical review of our knowledge of glo- 
mus tumors. The various names formerly 
given to it include: “painful subcutaneous 
tubercle (Wood, 1812),” “painful subcu- 
taneous fibroma (Tellaux),” “painful sub- 
cutaneous angioma (Monod),” “sub-ungual 
perithelioma (Muller),” “colloid sarcoma 
(Heller)” and “angiosarcoma (Kolaczek).” 
The tumor was first accurately describ- 
ed as “tumor of the neuromyo-arterial 
glomus” or “glomic tumor” by Masson as 
recently as 1924. He showed that glomic 
tumors originate from the digital glomus 
and faithfully reproduce its structure. 

Stout’s description may be summarized as 
follows: the glomus tumor on cross section 
is seen to consist of a small tangled mass of 
blood-vessels enclosed within a capsule. Mi- 
croscopically, the vessels are endothelial- 
lined and supported by a fine fibrous net- 
work. The rest of the wall is made up of 
peculiar cuboid or rounded “glomus” cells 
(usually referred to as epithelioid cells of 
Masson) and smooth muscle well differen- 
tiated or in an embryonal form in which the 
smooth muscle fibers are found within the 
cytoplasm of the epithelioid cells. The glo- 
mus cells are quite distinctive, having well 
defined cell outlines, accentuated by delicate 
collagen fibers which separate every cell 
from its neighbor. The cytoplasm is pale, 
sometimes vacuolated, which brings into 
sharp relief the nucleus, which is volumi- 
nous, centrally placed, globular or ovoid. 
Myelinated nerves are generally found in 
bundles in or near the capsule (can be seen 
in ordinary stains). Also present are nu- 
merous slender non-myelinated nerve fibers 
beneath the capsule and the epithelioid cells. 

Differential Diagnosis 

Other tumors which may be confused on 
account of their size or location are: neu- 
rofibromata, which are usually multiple and 
have no discoloration ; sub-ungual fibromata, 
which are not so painful and have no dis- 
coloration ; and melanoblastomata. which 


207 


GLOMUS TUMOR— MEYERS 


are usually of short duration, are not pain- 
ful or tender unless ulcerated, and which 
early usually show metastatic lesions. The 
other tumors (Pacinian body tumor, exos- 
tosis, papilloma, enchondroma, angio-kera- 
toma, nevi, cysts) can be ruled out either by 
their lack of color or absence of exquisite 
pain and tenderness. None of these are as 
exquisitely painful as glomus tumors. 

Treatment 

Surgical removal or destruction of the 
tumor have been the successful forms of 
treatment carried out. However, if search 
is not careful, the tumor may be missed. 
The tumor is benign, but two cases are re- 
ported in which the tumor recurred. The 
nail has regenerated normally when it was 
removed. 

Comments 

The origin of the glomus tumors in the 
normal digital glomus is discussed. A brief 
pathological and clinical description is given. 
Four new cases are reported, demonstrating 
further their frequency of occurrence in 
the fingers and in Jewish women. The one 
man not yet operated upon presents the 
classical symptoms and clinical findings. 
The exquisite pain and localized tenderness 
can lead one to make a diagnosis without 
actually palpating a tumor or seeing a dis- 
coloration. When the characteristic discol- 
oration and tenderness under the nail is 
seen, the lesion should be quickly recognized 
and removed. Of the four cases reported, 
two were neither palpable nor visible on 
physical examination and in both cases the 
characteristic symptoms were apparently un- 
recognized during their five and ten years’ 
duration. Of the four cases, three occured 
in females and one in a male. Of the four 
tumors, three were in the fingers and one 


in the thigh. In two cases the tumor was 
sub-ungual, one male and one female. All 
the patients are members of the Jewish race 
and adults. The age at onset ranged from 
seventeen to fifty years. The duration of 
symptoms was at least three years, and even 
as long as ten years in two of the cases 
reported. 

Glomus tumors are not always visible or 
palpable, as they are often very small and 
may be situated in the subcutaneous tissue. 
Operation on these patients is indicated, and 
their location can be determined by accurate 
search for the small point of exquisite ten- 
derness which signifies their presence. 

Summary 

Four cases of glomus tumor are reported. 
The distressing, disabling nature of this 
small and recently better known tumor 
makes it of extreme importance in early 
recognition and surgical removal which, al- 
most uniformly, gives complete relief of 
symptoms. 

Since presenting this paper for publication the 
author has removed a glomus tumor from under 
the finger nail of an additional patient. 

Bibliography 

Adair, F. E. : Am. Jour. Surg., 25:1, 1934. 

Rergstrand, H.: Am. Jour. Cancer, 29:470, (March) 1937. 

Cole, H. X., and Sroub, W. E. : Jour. A.M.A., 107:428, 

(August 8) 1936. 

Tirka, F. J., and Scuderi, C. S. : Tour. A.M.A., 107:201, 

(July 18) 1936. 

Kolodny, A.: Ann. Surg., 107:128-131, (Jan.) 1938. 

Lewis, Dean, and Geschichter, C. F. : Jour. A.M.A., 105: 

775, (September 7) 1935. 

Love, J. G. : Proc. Staff Meet. Mayo Clinic, 10:593, 1935. 

Mason, M., and Weil, A.: Surg., Gynec. and Obstet., 58: 

807, (May) 1934. 

Masson, P. : (a) Lyon Chir., 41:757, 1924. (b) Arch, pa le 
Sc. Med., 50:1, 1927. 

Popoff, N. W. : Arch. Path., 18:295, (September) 1934. 
Radasch, H. E. : Arch. Path., 23:615-633. (May) 1937. 
Raisman, V., and Mayer, L. : Arch. Surg., 30:911, (Tune) 

1935. 

Schoch, A. C.. and Aronson, H. S. : Texas State Med. Jour., 
32:545, (December) 1936. 

Stout, A. P. : Am. Tour. Cancer, 24:255, (June) 1935. 
Theis, F. V.: Arch! Surg., 34:1. (Jan.) 1937. 

Weidman, F. D., and Wise, F.: Arch. Derm, and Svph.. 

35:414, (March) 1937. 


208 


[our. M.S.M.S. 


THE MARE SERUM HORMONE IN THE TREATMENT OF 
CERTAIN ENDOCRINE DYSFUNCTIONS IN WOMEN 

A Clinical Study 

ROBERT B. KENNEDY, M.D., and CARL F. SHELTON, M.D. 

DETROIT, MICHIGAN 

Since the discovery of the pituitary-gonad relationship by Smith, 12 gonad stimulating 
substances have been prepared from a number of sources, including anterior pituitary 
gland, human pregnancy urine, castrate or menopausal urine and human placenta. The 
enormous physiological literature on this subject offers satisfactory evidence that these 
substances are capable of producing follicle stimulation, ovulation and corpus luteum for- 
mation in laboratory animals. 

Because of its availability, the gonad stimulating fraction of pregnancy urine (prolan, 


antuitrin-S, et cetera) has received the most 
extensive clinical study. The numerous pub- 
lications bearing on this subject have been 
recently reviewed by Jeff coate, 10 from which 
we conclude that these pituitary-like hor- 
mones from urine act differently in the hu- 
man than in the laboratory animals. Appar- 
ently these substances do not produce folli- 
cle stimulation or luteinization in the hu- 
man ovary. The work of Hamblen 7 would 
suggest that extract of pregnancy urine 
(antuitrin-S) may produce cystic degenera- 
tion in mature or maturing follicles, which 
may explain its mode of action in the treat- 
ment of certain types of functional uterine 
bleeding. 

Hamblen 8 has studied human ovaries aft- 
er administration of a gonadotropic frac- 
tion of anterior pituitary. He observed no 
histological changes which might be attrib- 
uted to the hormones injected but points out 
the possibility that the dosage may have 
been too small. 

Novak 11 has discussed the shortcomings 
of prolan preparations from urine as gonad 
stimulants in the treatment of amenorrhea, 
and has suggested that a true pituitary sex 
stimulation would be preferable in those 
amenorrheas where the ovaries are primar- 
ily at fault. He has also pointed out the 
fact that some cases of sterility and of func- 
tional uterine bleeding are associated with 
the failure of ovulation. It would appear 
that in such cases a hormone substance ca- 
pable of producing ovulation would offer 
the most hopeful and logical form of 
therapy. 

A new source of gonad stimulating hor- 
mone was discovered in 1930 by Cole and 
Hart 4 in the blood of pregnant mares. The 
studies of Goss and Cole, 6 Catchpole and 
Lyons, 3 and Hamburger, 9 have demonstrat- 

M arch, 1Q3Q 


ed that this hormone differs from that oc- 
curring in pregnancy urine and closely re- 
sembles extracts of the anterior pituitary 
gland in physiological properties. By the in- 
jection of pregnant mare serum these work- 
ers were successful in producing fertile ovu- 
lation in rats, ewes, sows and cows. This 
activity has received recognition in veter- 
inary practice. 

By fractionating pregnant mare plasma 
with acetone and with the use of isoelectric 
precipitation procedures, Cartland and Nel- 
son 2 have obtained a highly purified gonado- 
tropic fraction which is suitable for clinical 
study. Davis and Koff 5 have reported the 
production of ovulation in women by the 
injection of this hormone prepared from 
mare serum. These results, together with 
the physiological literature, would indicate 
that the mare serum hormone may be capa- 
ble of stimulating the normal process of 
ovulation and corpus luteum formation in 
the human. Bowes 1 has reported prelimi- 
nary studies on five cases of menstrual dys- 
function treated with mare serum hormone. 

Our interest in this newly available hor- 
mone has led us to study its use in the treat- 
ment of certain cases of amenorrhea, func- 
tional uterine hemorrhage, and more specif- 
ically to some interference with the normal 
process of follicle development, ovulation, 
and corpus luteum formation. Thus, we 
have administered the mare serum hormone 
to determine if clinical improvement can be 
accomplished by restoration of normal ova- 
rian function. 

Experiments 

The mare serum hormone used in these 
studies was prepared by the method of Cart- 
land and Nelson. 2 This preparation was 


209 


MARE SERUM HORMONE— KENNEDY AND SHELTON 




supplied to us in the form of sterile hypo- 
dermic tablets (gonadogen) which consti- 
tutes a stable form of the hormone in a 
highly purified state, from which a fresh 
sterile solution can be readily prepared at 
the time of injection. The gonadogen used 
in these experiments is biologically stand- 
ardized by subcutaneous injection on three 
successive day into twenty-one to twenty- 
three day old female rats. The rat unit is 
defined as the minimum dose which so ad- 
ministered will produce at autopsy ninety- 
six hours after the first injection a pair of 
ovaries weighing 65 milligrams, which is 
five times the weight of control ovaries. 

Although the hormone preparation is sub- 
stantially free of serum proteins, we have 
adopted the regular precaution of making 
an intradermal test for sensitivity before 
proceeding with the therapeutic injections. 

The following brief case reports are 
amenorrhea cases that were treated with the 
pregnant mare serum hormone: 

Case 1 . — A twenty-eight-year old married woman 
complained of amenorrhea for a period of three 
months’ duration occurring nine months after a nor- 
mal pregnancy. Physical examination revealed a 
small uterus and small, hard ovaries. Regularity was 
established with 50 unit doses of gonadogen given 
intramuscularly twelve days before the expected pe- 
riod. Duration of flow at the time of this writing 
is five days. 

Case 2 . — A thirty-three year old married multip- 
arous woman complained of menstruation at three- 
month intervals. B. M. R. was — 32. Regularity was 
established with the use of 50 units of gonadogen 
given at monthly intervals for seven months along 
with thyroid therapy. At the time of writing, the 
patient is pregnant. 

Case 3 . — A twenty-two-year old married woman, 
whose menses began at 14 and occurred every thirty 
to thirty-three days with a seven-day flow, had a 
miscarriage three years ago at three months. Since 
then she has had only a scant brownish discharge at 
monthly intervals. At laparotomy after finding 
large, sclerotic ovaries with a very tough and thick- 
ened tunica, a resection was done. The patient was 
then given 50 units of gonadogen at monthly in- 
tervals. The cycle then became regular with normal 
flow. 

Case 4 . — A twenty-seven-year old married woman 
complained of a scant serous discharge for the past 
six months. Her previous menstrual cycle was a 
regular twenty-eight-day type which began at the 
age of thirteen. Two weeks after the first intra- 
muscular injection of 50 units of gonadogen the 
menses lasted two days. The patient has now had 
eight 50 unit injections at monthly intervals and the 
cycle is of three to four days’ duration with a nor- 
mal flow. 

Case 5.— A thirty-nine-year old married woman 
complained of amenorrhea for six months, follow- 
ing one pregnancy with spontaneous abortion. Gon- 
adogen successfully regulated the cycle. 

210 


Case 6 . — A thirty-two-year old married woman 
complained of menses occurring every two to three 
months. She had had no pregnancies. The periods 
were regulated at monthly intervals with 50 unit 
doses of gonadogen. 

Case 7 . — A thirty-four-year old married woman 
whose menses began at 14 with a regular thirty-day 
cycle complained of sixty-day periods since a Rubin 
test and curettement four years previously. She has 
been married eleven years with no pregnancies. Gon- 
adogen in 50 unit doses did not alter the menses. 
The patient showed evidence of pituitary dysfunc- 
tion and has been definitely diagnosed as Frohlich’s 
syndrome. 

Case 8 . — An eighteen-year old single girl whose 
menses began at fifteen with an irregular one-to-six- 
day flow complained of four to six-month periods 
of amenorrhea. Bimanual examination revealed no 
pelvic pathology. Gonadogen in 50 unit doses 
brought the periods to monthly intervals with a flow 
of two days’ duration. 

Case 9. — An eighteen-year old single girl whose 
menses began at 15 with an irregular flow of five 
to six days developed amenorrhea and periods of 
scanty flow for the past two years. She was well 
developed and about ten pounds overweight. On 
pelvic examination, the uterus and ovaries were 
small. Thyro-ovarian compound in 1936 did not im- 
prove the condition. Ovarian extract in 1936 gave 
similar results. The patient was then given antu- 
itrin-S and theelin for four months, after which her 
periods became somewhat more regular but still 
scanty. Examination of the pelvis during the course 
of an appendectomy in 1938 showed small ovaries 
and a poorly developed uterus. Gonadogen was 
then started in 50 unit doses once a month. The 
periods became regular at monthly intervals with a 
two-day duration of flow. 

Case 10 . — A thirty-two-year old married woman 
with two children (youngest eight months) com- 
plained of amenorrhea and painful breasts for the 
past five months. The general impression was one 
of undernourishment and anemia. On pelvic exami- 
nation the uterus was of normal size and in mid- 
position with ovaries of normal size. Periods pre- 
vious to the last pregnancy were the regular twenty- 
eight-day type of four days’ duration. Gonadogen in 
50 unit doses given at monthly intervals for five 
months regulated the periods and the injections were 
discontinued. The patient returned four months 
later to report that her menses have been regular 
since. 

Three cases of menorrhagia were treated 
with the pregnant mare serum hormone: 

Case 1 . — An eighteen-year old single girl whose 
menses began at thirteen complained for the past 
several months of a scant flow which has continued 
all month. By pelvic examination pregnancy was 
excluded. A normal uterus and normal sized ovaries 
were found. After 50 units of gonadogen at month- 
ly intervals for eleven months, the quantity of flow 
increased but the irregularity persisted. 

Case 2 . — A thirty-year old single woman whose 
periods began at eleven and were never regular 
complained of a flow of two weeks’ duration. On bi- 
manual examination there were large ovaries and a 
normal sized uterus. This patient was given 10 in- 
jections of 50 unit doses at monthly intervals; the 
periods were reduced to a five to seven-day flow. 

Jour. M.S.M.S. 


MARE SERUM HORMONE— KENNEDY AND SHELTON 


Case 3 . — A twenty-nine-year old married woman 
whose menses began at fifteen and were always reg- 
ular complained of a two-week flow for the past 
three periods. Pelvic examination was negative. 
Seven injections were given at monthly intervals. 
After the first injection the flow lasted three weeks; 
since then it has diminished to five days. 

Discussion 

The cases reported above were in no way 
selected but represent a cross-section of of- 
fice patients complaining of menstrual dis- 
orders and in whom no gross pelvic pathol- 
ogy was found. Ten cases of amenorrhea 
and three cases of menorrhagia were sub- 
jected to this medication. 

The work of Davis and Koff, in which 
they produced ovulation in the human fe- 
male, was accomplished with the intrave- 
nous use of the hormone. In our series the 
intramuscular route was used with favor- 
able results. Before administration, the pa- 
tients were carefully tested for protein hy- 
persensitivity. 

It is perhaps of special interest to note 
that there were two cases in which amenor- 
rhea was present for seven and twelve days, 
respectively, occurring for the first time. In 
each case, one injection of 40 units of go- 
nadogen was sufficient to start menstruation. 

Pregnant mare serum exhibits certain 
definite physiological differences from prep- 
arations of urinary prolan. The physiologi- 
cal studies on both animals and humans in- 
dicate that this hormone possesses gonado- 
tropic properties closely resembling those of 
the anterior pituitary gland. In proper dos- 
age many workers have shown that it is ca- 
pable of stimulating normal ovarian func- 
tion. The action in general is similar to that 
of the anticipated uses of the various prolan 
substances. Because of its availability the 
gonad-stimulating fraction of pregnancy 
urine (prolan) has received extensive clini- 
cal study. Jeff coate 10 has recently reviewed 
the enormous literature on the urinary pro- 
lans, from which we conclude that these 
substances act differently in the human than 
they do in laboratory animals and therefore 
do not fulfil the original hopes entertained 
for them as a true pituitary type of gonado- 
tropic hormone. The new mare serum hor- 
mone seems to fulfil the desired requirement 
of an anterior pituitary-like gonadotropic 
substance. 

Although we are unable to offer any re- 
marks regarding the problem of sterility or 
the production of ovulation in women with 

March, 1939 


the use of this hormone, the recent work of 
Davis and Koff has disclosed some interest- 
ing facts in regard to the production of 
ovulation. Using Gonadogen, they have for 
the first time been able to demonstrate the 
artificial production of ovulation in women, 
followed by normal corpus luteum develop- 
ment. Using a single intravenous injection 
of 50 to 60 Upjohn units, they have been 
able to produce experimental ovulation in 
normal women within twenty-four to thirty- 
six hours following injection. 

Summary 

Although some of the results are nega- 
tive, we think this is what one might expect 
in view of the fact that the exact cause of 
menstrual irregularities is difficult to diag- 
nose. 

It is possible that more consistent results 
will be obtained therapeutically with gonad- 
ogen when we find the specific type of cases 
in which ovarian dysfunction is the primary 
cause. 

Although it is clearly impossible to draw 
any valid conclusions from such a small se- 
ries of cases, the results, particularly in 
some of the amenorrheas, seem to be suffi- 
ciently hopeful to justify mention. In our 
series, favorable results were obtained with 
the intramuscular use of the pregnant mare 
serum hormone. 

The fact that it is not possible to tell by 
clinical means alone the true nature of men- 
struation produced by any hormonic prepa- 
ration points to the helpful aid of the cu- 
rette in evaluating the endometrial changes 
that accompany menstrual dysfunction. 

Bibliography 

1. Bowes, Kenneth: Treatment of menstrual irregularities 

by a new sex hormone preparation. Brit. Med. Jour., 
2:904, (Nov. 6) 1937. 

2. Cartland, G. F., and Nelson, J. W. : The preparation 

and purification of extracts containing the gonad-stimu- 
lating hormone of pregnant mare serum. Jour. Biol. 
Chem., 119:59, (June) 1937. 

3. Catchpole, H. R., and Lyons, W. R. : Gonad-stimulating 
hormone of pregnant mares. Am. Jour. Anat., 55: 
167-227, (Sept.) 1934. 

4. Cole, H. H., and Hart, G. H. : The potency of blood 
serum of mares in progressive stages of pregnancy in 
effecting the sexual maturity of the immature rat. Am. 
Jour. Physiol., 93:57, No. 1, (May) 1930. 

5. Davis, M. E., and Koff, A. E. : The experimental pro- 
duction of ovulation in the human subject. Am. Jour. 
Obst. Gynec., 36:183, (Aug.) 1938. 

6. Goss, Harold, and Cole, H. H. : Sex hormones in 

the blood serum of mares. Endocrinology, 15:214, No. 
3. (May-June) 1931. 

7. Hamblen, E. C., M.D. : Results of preoperative ad- 

ministration of an extract of pregnancy urine. Endo- 
crinology, 19:169, No. 2, (March-April) 1935. 

8. Hamblen, E. C., M.D.: Study of ovaries after admin- 

istration of a gonadotropic principle of anterior pitui- 
tary. Endocrinology, 20:321, No. 3, (May) 1936. 

9. Hamburger, C. : Further studies on the- gonadotropic 

hormone of the pregnant mare. Endokrinologie, 17:8-21, 
1936. 


211 


GALLSTONE COLIC— LARSSON 


10. Jeffcoate, T. N. A.: Treatment of functional uterine 

hemorrhage by means of gonadotropic and ovarian hor- 
mones. Jour. Obst. Gynec. Brit. Emp., 44:31-85, (Feb.) 
1937. 

11. Novak, E., M.D. : A brief epitome of gynecologic en- 


docrinology and organotherapy. Am. Jour. Obst. Gynec., 
32:887, No. 5 (Nov.) 1936. 

12. Smith, P. E. : Hastening development of female genital 

system by daily homoplastic pituitary transplants. Proc. 
Soc. Exper. Biol. Med., 24:131, (Nov.) 1926. 


GALLSTONE COLIC OR GASTRIC CRISIS 
A Case Report 

B. HJALMAR LARSSON, M.S., M.D. 

DETROIT, MICHIGAN 


A careful search in the Index Catalog of the Library of the Surgeon General’s Office, 
United States Army, since 1915, fails to reveal any report of cases where the gastric 
crisis of tabes dorsalis has been confused with biliary colic due to calculi or vice versa. 
In The Quarterly Cumulative Index Medicus from 1926 and up to June 1938, no 
cases of a similar nature have been reported. E. Herskovitz reports a case in roentgen- 
praxis (Vol. 9:614-616, September, 1937), in which renal calculi provoked a pseudo- 
tabetic crisis. The Quarterly Cumulative Index Medicus refers to numerous case reports 
of duodenal and gastric ulcer which simu- 


late gastric crises of tabes dorsalis and vice 
versa. Apparently there are patients with 
gastric crises of tabes dorsalis who at the 
same time are suffering from gall-bladder 
disease and gallstone colic. 1 should like to 
report one such case since it presents some 
unusual features. 

The patient was a Swedish-American toolmaker, 
aged thirty-nine years, who entered Harper Hospi- 
tal August 3, 1935. His family history was irrele- 
vant. Eight years ago he had an attack of jaun- 
dice of eight days’ duration associated with sharp 
epigastric pain which radiated to the right shoul- 
der. Ten months and again six months ago he had 
similar attacks accompanied by belching, nausea 
and vomiting, but no jaundice. He denied venereal 
diseases. He had been a steady worker, and had 
smoked many cigarettes and occasionally drank 
whisky in moderate amounts. His bowels had 
been constipated. There had been moderate loss 
of weight. 

He had not been feeling well for the past two 
weeks. Eight days ago he returned home from 

his regular work and after supper he was seized 
with violent pain in the epigastrium which began 
in the right upper quadrant and travelled toward 
the back, and was accompanied by nausea and 
vomiting. He was relieved only by injection of 

morphine. A dull constant pain remained after 

the acute attack had subsided. Since then he has 
had a number of attacks. Cathartics relieved him 
somewhat from the abdominal distress but made 
him more nauseated and caused vomiting. The 
vomitus was yellow and sour but never contained 
blood. He had had no melena. The attacks had 
no relation to meals but were sometimes brought 
on by a drink of whisky. 

Physical examination revealed a tall, well de- 
veloped man, fairly well nourished, lying com- 

fortably in bed. Constitutionally he was of the 
ulcer type. His pupils were equal, round, and re- 
acted to light and accommodation. The sclene 
were clear. The abdominal wall was firm and 
slightly tender to palpation, there were no palpable 
masses. The spleen appeared slightly enlarged to 
percussion. The reflexes were physiological. The 


blood count revealed : 4,880,000 red cells, 6,800 

white cells with 58 per cent polymorphonuclears. 
Serologic: Kahn negative, sugar 0.174 per cent. 
N.P.N. 33.3 mgs., icteric index 5. The urine was 
alkaline, 1.015 specific gravity with a trace of al- 
bumin, acetone 3+, no sugar and no casts. 

Roentgenologic study revealed no organic lesion 
of the stomach, duodenum, small or large bowel. 

Cholecystography showed a large gall bladder, 
of the pendulous type. It concentrated the dye 
faintly and exhibited some contractility after a 
fat meal. There were multiple shadows of nega- 
tive density. Conclusions : Definite evidence of 

cholelithiasis. 

Hospital course : Under spinal analgesia the 

patient was operated upon 8/9/35. The gall blad- 
der was unusually large with the fundus dropping 
down toward the pelvis. It contained a quantity of 
small, black faceted calculi, of the same approx- 
imate size. No calculi were palpated in the cystic, 
hepatic or common ducts. Cholecystectomy was per- 
formed with double ligature of the cystic duct and 
closure without drainage. 

The tissue report showed chronic cholecystitis and 
the post-operative convalescence was smooth. The 
patient was discharged on the tenth postoperative 
day. 

Subsequent course : Fourteen days after the oper- 
ation he was readmitted with the history of return 
of nausea and vomiting but no jaundice. There was 
no history of acute pain but rather a fe'eling of dis- 
tress in the epigastrium. This was the first of six 
such episodes. The treatment during hospitalization 
was usually the same and consisted of adequate ad- 
ministration of parenteral fluids, solution of glucose 
and sedatives. The improvement was rapid and the 
hospitalization varied from one to six days. There 
were long periods during which the patient attended 
to his regular work in the factory with compara- 
tively little discomfort. During the first three- 
month period following the operation, he gained 
twenty-five pounds of weight. Physical examination 
of the patient at each entry were essentially the 
same. At times, there was a noticeable icteric tint 
to the sclene but pupillary and patellar reflexes 
were considerably active as on the first admittance. 
There was an occasional rise in the white blood 
count, the highest recorded was 11,000 with 77 per 
cent polymorphonuclears. Repeated urine exami- 


212 


ADENOMA OF THE STOMACH— HILT 


nations failed to show the presence of bile. Three 
Kahn blood tests were reported negative. Van den 
Bergh direct and indirect were negative. The icteric 
index was normal. A repeated Roentgen exami- 
nation revealed no lesions in the pyloric end of the 
stomach or in the duodenum to account for the 
patient’s symptoms. During the last entry it was 
noted that the patient’s patellar reflexes were rather 
sluggish and this prompted a spinal fluid exami- 
nation. This revealed a Kahn 4+ positive, the gold 
curve was 1,233,322,100 and there were 14 white 
blood cells per 1 c.c. of spinal fluid with a slight in- 
crease in the globulin. 

The patient was informed of the situation and 
returned to his usual work. After two weeks he 
was reported missing and a few days later was 
found dead. An autopsy was performed at the 
University Hospital at Ann Arbor. The report read : 

“We found that the gall bladder had been re- 
moved and that the common duct was fully patent 
throughout and in excellent functional condition. 
No calculi were found in either the common duct 
or stump of the cystic duct and there was no evi- 
dence of any biliary obstruction. We felt that the 
results of the operation were exceedingly satisfac- 
tory. There was no evidence of gastric or duodenal 
ulcer. Putrefactive changes were too far advanced 
to permit a study of microscopic details of the 
spinal cord. The death was due to hanging and 
was undoubtedly suicidal. (Signed) John C. Bugher, 
Assistant Professor of Pathology.” 

Discussion 

The clinical history in this case supported 
by Roentgen evidence and operative findings 
warranted a diagnosis of gall-bladder dis- 
ease with cholelithiasis. The post-cholecys- 
tectomy syndrome appeared to be typical of 
the complications which occasionally are en- 
countered in gall-bladder surgery. During 


this patient’s six re-entries the question pre- 
sented itself whether or not there may have 
been a remaining common duct calculus or 
some interference with the sphincter mech- 
anism (Oddi) causing a partial obstruction. 
Later, cholangitis was suspected. The evi- 
dence which would have indicated a second- 
ary surgical procedure on the extra-hepatic 
biliary ducts was not definite. The repeated 
negative Kahn blood tests, the characteris- 
tic absence or weakness of knee-jerks and 
the specific Argyll-Robertson phenomenon 
usually associated with tabes dorsalis did 
not suggest a possible pre-ataxic stage of 
neuro-syphilis. It is known that gastric 
crisis may occur early in a case of tabes 
dorsalis before the usual signs of disease 
of the cord have manifested themselves 
definitely. In this case there was no his- 
tory suggestive of either lightning pains 
or bladder disturbance. The autopsy re- 
port helped to clear up what seemed to be 
a complicated diagnostic problem. The sero- 
logical findings in the spinal fluid proved 
that there was active neurosyphilitic dis- 
ease present. Considering the final appear- 
ance of sluggish knee-jerks and the spinal 
fluid changes as well as the crises-like at- 
tacks after operation without any local find- 
ings in the bile ducts it is apparent that the 
diagnosis of tabes dorsalis was justified. 

10 Peterboro Street 


ADENOMA OF THE STOMACH 

LAURENCE M. HILT, M.D.* 

Butterworth Hospital 
GRAND RAPIDS, MICHIGAN 

The known tendency of carcinoma to develop upon an adenoma was brought to our 
attention in a case which appeared to be a benign lesion of the stomach on first exam- 
ination but which eighteen months later showed radiologic evidence of malignant devel- 
opment. The first examination showed marked similarity between this case and two cases 
of adenoma of the stomach which were verified as such by pathologic section. 

According to Kaufmann, “Adenomatous polyps are composed essentially of prolifer- 
ated mucosal glands covered with a single layer of cylindrical epithelium with many 
goblet cells. Perfect uniformity of the epi- 
thelium does not exist; indeed these epi- 
thelial tumors show a certain degree of 
polymorphism.” The majority of the cases 
are single, but they may be multiple. Aden- 
omas do not disintegrate but may become 

*The material for the paper was collected while as- 
sociated with Patton, Evans & Herndon, and St. John’s 
Hospital,. Springfield, Illinois. 

Appreciation is hereby expressed to Dr. O. L. Zelle for 
obtaining the post mortem in Case 3. 

March, 1939 


ulcerated by peptic digestion. Carcinoma 
developing upon an adenoma occurs less 
frequently in the stomach than it does in 
the intestines. It is also possible that an 
adenoma may grow in the presence of a 
carcinoma. Unlike carcinoma, adenomas do 
not penetrate the deep layers but grow from 
the mucosa into the stomach cavity. The 


213 


ADENOMA OF THE STOMACH— HILT 


adenomatous growth does not cross the mus- 
cularis mucosae. 

The relationship of inflammatory changes 
to the formation of adenomatous polyps in 
other organs, especially the nose, has been 



Fig. 1. Case 1. 


cited. Mills believed that the lesion begins 
as a simple thickening of the mucous mem- 
brane. 

X-ray Characteristics 

The combination of fluoroscopic and 
roentgenological examination is essential. 
In one case films taken in one position failed 
to show the lesion; whereas films taken in 
another position gave definite evidence of 
the lesion. The presence of a tumor was 
very easily demonstrated fluoroscopically in 
another case by manipulation in different 
positions. 

It is our belief that it is by careful x-ray 
examination that this diagnosis is made. 

The principal x-ray signs are: 

1. Filling defects, single or multiple, hav- 
ing vacuolated appearance. The lesion may 
be movable or fixed. 

2. The majority of the lesions are found 
in the pyloric region. It is possible for a 
lesion with a long pedicle to extend into 
the duodenum and be mistaken for a duo- 
denal lesion. 

3. The size may vary from a pea to a 
fetal head. 

4. The peristaltic waves are not inter- 
fered with on either curvature of the stom- 
ach. 


5. There may be a five-hour residue, al- 
though in this series there was no residue. 

Clinical Findings 

1. Anemia is one of the most constant 



Fig. 2. Case 2. 


findings. The anemia is usually of the sec- 
ondary type although cases have been re- 
corded in which the characteristics were 
those of a primary anemia and the patients 
treated as such. Any obscure case of sec- 
ondary anemia warrants an examination of 
the gastro-intestinal tract with the probabil- 
ity of a benign tumor in mind. 

2. There may be symptoms of obstruc- 
tion of the pylorus, usually of the intermit- 
tent type. 

3. Intervals of freedom from pain have 
also been noted. These intervals are usually 
of variable length. The distress may or 
may not simulate an ulcer. 

4. Achlorhydria is usually always pres- 
ent. 

5. There mav be a history of vomiting, 
hematemesis and diarrhea. 

6. The tumor mass may occasionally be 
large enough to be palpated. 

7. Muscular rigidity of the abdomen may 
be present. 

8. Particles of tissue have been found in 
the gastric contents. This occurred in one 
of our cases. 

9. The feces may contain occult blooT 

Tour. M.S.M.S. 


214 




ADENOMA OF THE STOMACH— HILT 


Case 1 . — A colored woman, H. L., aged forty- 
seven, consulted Dr. R. F. Herndon in February. 
She had been without symptoms of any sort until 
about one year ago when she had diarrhea of var- 
iable severity for three or four weeks. About two 
weeks later, she had an acute upset with nausea, 


negative for occult blood. RBC 2, 240, OCX); Hemo- 
globin 37 per cent (4-24-31). RBC 3,400,000; Hemo- 
globin 45 per cent (8-4-31). RBC 3,350,000 (9-2-31). 
Hemoglobin 44 per cent (8-3-31). Fluoroscopic ex- 
amination demonstrated constant filling defect of 
the lesser curvature of the stomach. Roentgeno- 



Fig. 3. Case 3. a, Original examination, b, Normal appear ing stomach. Radiograph made in different positions than 
others, c, Eighteen months later. 


vomiting and vertigo. These attacks lasted about a 
day or two, occurring about twice a week until six 
months ago when they ceased. For the last six 
months she has had a dull pain in the left upper 
quadrant, constant in character, which is increased 
by taking food. Food produces bloating. She spits 
up watery material which does not taste sour. She 
has some nausea but no vomiting. Appetite is good 
but patient is reluctant to eat. 

Physical examination revealed no evidence of a 
mass in the abdomen. Pelvic and rectal examinations 
negative. Urine negative. Hemoglobin, 70 per cent. 
Red blood cells, 3,850,000. Kahn negative. 

Gastric analysis showed an achlorhydria. The 
feces showed no macroscopic evidence of blood. 
Benzidine reaction for occult blood was positive. 

A small piece of tissue about 1 bv 1 by 0.3 cm. 
was found in the gastric analysis. On section, this 
appeared to be made up of epithelial cells which 
showed an orderly arrangement. 

Fluoroscopic examination showed a filling defect 
in the pars media which was vaculated in appear- 
ance, constant, moveable and on changes in position 
could be obliterated. The peristaltic waves were 
normal on both curvatures of the stomach. The 
pylorus was regular in outline. The duodenal bulb 
was regular in outline. The stomach was empty at 
the end of five hours. Roentgenographic exami- 
nation confirmed the fluoroscopic findings. The roent- 
genological diagnosis was tumor of the stomach, 
probably benign. 

At operation by Dr. C. L. Patton, a mass about 
6 by 2 cm., cauliflower-like in appearance, was found 
attached to the anterior stomach wall. This was 
removed. The attachment of the mass to the 
stomach was by a broad base but there was appar- 
ently no infiltration of the stomach wall beyond 
the tumor. Pathological section revealed an aden- 
oma. 

Six years later, this patient was alive and well 
with no symptoms or complaints referable to stom- 
ach, and weighed 160 pounds in comparison to 116 
pounds at the first examination. 

Case 2 . — A white man, L. J., aged sixty-one, while 
in the hospital in February with an infection of the 
right knee complained of pain in the abdomen. Gas- 
tric analysis — achlorhydria. Urine negative. Feces 

March, 1939 


graphic examination confirmed the fluoroscopic find- 
ings. A diagnosis of tumor of the stomach, probably 
malignant, was made. There was an increasing an- 
emia of the patient. In October, a blood transfusion 
was made. On October 3, an operation was per- 
formed. A freely moveable mass about seven by 
seven centimeters was found in the pyloric portion 
of the stomach. This was removed. A blood trans- 
fusion was given at the completion of the operation. 
The patient died October 7. Microscopic section re- 
vealed an adenoma of the stomach. 

Case 3 . — A white man, L. R., aged seventy, con- 
sulted Dr. R. F. Herndon. He had had no serious 
illness in the last fifty years. Five months ago, the 
patient discovered an epigastric lump which he be- 
lieves has increased in size until it now feels about 
the size of a baseball. Constipation increased. Epi- 
gastric pain of intermittent frequency for about two 
years. Pain constant in character. Pain increases at 
night but never severe. Appetite good. Feels better 
after he eats. Occasional nausea but no vomiting. 
Weight 103 pounds. 

Physical examination revealed a mass in the 
epigastrium. Rectal and prostatic examinations were 
negative. Urine negative. Stool microscopically neg- 
ative. Benzidine reaction of fecus positive for oc- 
cult blood. Red blood cells 4,150,000. Hemoglobin, 
80. Gastric analyses demonstrated achlorhydria. 

Fluoroscopic study of the gastro-intestinal tract 
demonstrated a constant filling defect in the distal 
portion of the pars media. Peristaltic waves were 
normal on both curvatures of the stomach. No ir- 
regularities could be outlined on either curvature of 
the stomach. The distal portion of the pylorus and 
the duodenum were normal in outline. The stom- 
ach emptied at the end of four hours. Roentgen- 
ograms of the stomach confirmed the fluoroscopic 
observations except one film taken in a different 
position from the others was that of a normal 
stomach. 

Roentgenologic diagnosis of benign tumor was 
made. Operation advised but refused. 

Eighteen months later this patient was again 
examined. The patient’s chief complaint was an in- 
creasing weakness. There was no loss in appetite 
but increase in nausea and vomiting. The tumor 
mass was larger, more easily palpable. Weight, 85 
pounds. The patient was markedly jaundiced. Urine 

215 




REMOVAL OF BB SHOT WITH GIANT MAGNET— MCCLELLAND 


was negative. Kahn negative. Red blood count 
showed 2,700,000 cells and 28 per cent hemoglobin. 
Leukocytes were 8,150. Roentgenologic study dem- 
onstrated a marked filling defect in the stomach 
which extended from the distal portion of the pars 
media and included the pylorus. The vacuolated ap- 
pearance of the former examination could not be 
demonstrated. The peristaltic waves did not pass 
beyond the distal portion of the pars media. The 
duodenal cap was normal. No obstruction to the 
passage of the barium meal was noted. The stom- 
ach was empty at five hours. A roentgenological 
diagnosis of carcinoma of the stomach was made. 
Two months later this patient died. Postmortem 
confirmed the diagnosis of adeno-carcinoma of the 
stomach. 

Conclusions 

1. Roentgenologic examination may be 
the only means of diagnosis. 

2. Obscure cases of secondary anemia 
should be examined with the possibility of a 
benign gastric lesion, probably an adenoma. 

3. Achlorhydria is usually present. 

4. Pain in some form is usually present. 

5. From the roentgenologic examination 
it is impossible to differentiate the type of 


tumor; but in one case at the first exami- 
nation the similarity to two proven cases of 
adenoma with the subsequent evidence of 
malignancy form a basis to conclude that in 
the beginning the lesion was benign and an 
adenoma. 

6. All malignant appearing lesions of the 
stomach should be carefully considered as to 
the possibility of their being benign. 

Bibliography 

1. Balfour, D. C., and Henderson, E. F. : Benign tum- 

ors of the stomach. Ann. Surg., 85:354, (March) 1927. 

2. Baunn, H., and Pearl, F. : Diffuse gastric polyposis — 

adeno-papillomatis gastrica. Surg. Gynec. and Obstet., 
43:559, (Nov.) 1926. 

3. Carman, Russell D. : The Roentgen Diagnosis of Dis- 

eases of the Alimentary Canal. Second Edition. Phila- 
delphia: W. B. Saunders Company, 1920. 

4. Eleason, Pendergrass, and Wright: The roentgen-ray 

diagnosis of pedunculated growths. Am. Jour. Roent- 
genol. and Radium Therapy, 15:295, 1926. 

5. Ewing: Neoplastic Diseases. Second Edition. Philadel- 
phia: W. B. Saunders, 1922. 

6. Kaufmann: Pathology. Translated by Reiman. P. 

Blakiston’s Son & Company, 1930. 

7. Miller, T. G. : Polypoid carcinoma of the stomach. 

Jour. A.M.A., 76:229, (Jan. 22) 1921. 

8. Rigler, L. G. : Roentgenologic observations on benign 

tumor with a report of fifteen cases. Am. Jour. Surg., 
(Jan.) 1930. 


REMOVAL OF BB SHOT WITH GIANT MAGNET* 
carl c. McClelland, a.b., m.d., f.a.c.s. 

DETROIT, MICHIGAN 

BB shot were formerly made by pouring molten lead into molds. Today the process 
is the same except molten steel is used, so that the shot are attracted by a magnet. Some 
of the BB shot on the market have been copper coated. This does not affect the action of 
the magnet on them. I desire to report two cases where the giant magnet was successfully 


used in removing BB shot from the body. 

Case 1. — B. W., a girl aged thirteen, was playing 
in her own back yard. One hundred and fifty feet 
away a neighbor boy was shooting a BB air rifle. He 
saw the girl, took aim and fired. The shot pene- 
trated the right eye-ball, entering the vitreous cham- 
ber behind the lens on the nasal side. X-ray ex- 
amination six hours later showed the shot still in 
the globe 9 mm. back of the center of the cornea, 10 
mm. to the temporal side of the vertical meridian 
and 11 mm. below horizontal meridian. The anterior 
chamber was filled with blood ; the pupil dilated eas- 
ily. Details of fundus were not made out. There 
was very little reaction in the eye. The sclera was 
still white. Under local anesthesia a giant magnet 
was used, when the shot was easily drawn out 
through the wound of entry. The patient was given 
typhoid vaccine for protein reaction. She left the 
hospital in four days. Subsequent examination 
showed the lense had not been injured and there 

*From the Department of Ophthalmology and Oto-Laryn- 
gology, Grace Hospital, Detroit, Michigan. Read before the 
Detroit Ophthalmological Club. 


was no traumatic iritis. The vision was 20/20 with 
correction and has remained so for nine months, 
with no retina detachment. 

Case 2. — H. N., a boy aged three, while playing 
with BB shot put one in his left ear. Two un- 
successful attempts were made to remove the shot 
with forceps which only pushed the shot further 
in and caused traumatism with hemorrhage. I saw 
the child about four hours later. Examination 
showed the external canal full of blood clot. When 
this was washed away, a very little of the surface 
of the shot could be seen because of swelling and 
edema in the external canal. Remembering that the 
shot was steel, removal was easily done under ether 
anesthesia with the giant magnet, after the external 
canal had been packed with alcohol cotton for twelve 
hours. The shot was lying against the drum mem- 
brane. No inflammatory reaction followed. These 
BB shot had a diameter of 3.5 mm. and weighed 350 
mg. 


216 


Iour. M.S.M.S. 


CESAREAN SECTION: 338 CONSECUTIVE CASES* 


WARD F. SEELEY, M.D., F.A.C.S. 

DETROIT, MICHIGAN 


During the period of ten years from 1928 to 1937, inclusive, there were confined at 
Harper Hospital 13,358 patients, among whom 338 were delivered by cesarean section, 
an incidence of one in forty, or 2.5 per cent. This is quite similar to the frequency of the 
operation in the city of New York, 1930-1932, where the city-wide incidence was 2.2 per 
cent, and to that in Philadelphia, 1931-1933, where abdominal section occurred in 2.6 
per cent of all deliveries. In strictly hospital practice more frequent resort to cesarean 
section may be expected, as for instance at the Chicago Lying-In Hospital, Daily reports 
5.6 per cent cesareans among 8,871 hospi- 
tal deliveries. Furthermore, the incidence , . 

is likely to be higher in hospitals in which n lca 10ns 

the work is largely in the hands of spe- table ii 


cialists in the field of obstetrics, due to the 
reference of cases specifically for abdominal 
delivery. 

Type of Operation 

TABLE I 


Low Cervical 244 — 72.2% 

Classical 56 — 16.6% 


Disproportion .... 
Previous Section . 
Placenta Previa . . 

Cardiac 

Abrupto Placenta 
Nephritic Toxemia 
Pre-eclampsia .... 

Eclampsia 

Miscellaneous .... 


116 

109 

43 

12 

12 

9 

6 

2 

21 


Total 


338 


Porro 


38— 11.2% 


Total 338—100% 

Table I shows an overwhelming prepon- 
derance of the low cervical operation over 
other types. This is probably due to the 
quite general advocacy of this operation, in 
recent years, as a safer procedure, partic- 
ularly in infected or potentially infected 
cases. While I do not mean to infer that 
all low cervical operations were done for 
these indications, yet, it can be argued that 
if the procedure of choice in potentially in- 
fected patients the low section should be 
above reproach in clean cases. This method 
of reasoning undoubtedly accounts for its 
high occurrence (72.2 per cent) over a ten 
year period. 

Fifty-six (16.6 per cent) classical opera- 
tions were done in cases judged to be clean, 
among which were several cases of placenta 
previa occurring early in the series when 
this condition was thought to complicate 
the low operation. 

The Porro technic with amputation of the 
uterus supravaginally was done thirty-eight 
times (11.2 per cent) in cases of doubtful 
cleanliness, for uterine fibromata, for steril- 
ization, and abruptio placentae. 

*From the Department of Obstetrics and Gynecology, 
Harper Hospital. 


By far the greatest number of operations 
were done for the indications “dispropor- 
tion” and “previous section.” A closer 
scrutiny of “disproportion” shows that in a 
very high percentage it was considered to be 
pelvic, in a few instances a combination of 
an oversized head and a small pelvis, and 
with rarity only a large head without en- 
gagement. 

Previous section accounted for 109 cases 
or nearly one-third of the total. In 
many instances the indication for the first 
section was permanent. Nevertheless, we 
at Harper Hospital apparently believe 
that the dictum “once a cesarean always a 
cesarean” applies, and follow our belief in 
practice. Whether or not we are correct in 
our belief may be debated, but in our de- 
fense let it be said that there was no mortal- 
ity in the 109 cases operated with “previous 
section” charted as the indication. 

Cesarean section was done forty-three 
times for placenta previa, in patients who 
had had adequate prenatal supervision, in 
relatively good condition, and either not in 
labor or very early in labor. There was no 
mortality in this group. 

It is well known, and quite universally 
conceded, that the treatment of placenta 
previa should depend to a great extent upon 
the condition of the patient when first seen. 


March, 1939 


217 


CESAREAN SECTION— SEELEY 


For this reason patients in poor condition, 
well advanced in labor, particularly if they 
be multiparse, with the marginal or lateral 
varieties, are safer if treated by more con- 
servative methods. The more so if ill ad- 
vised vaginal examination or tamponade has 
been done. On the other hand, patients 
seen from the first bleeding, not in labor 
or early in labor, particularly if they be 
primiparse, without vaginal manipulation, 
can be safely delivered by cesarean section. 
The value of blood transfusion in these 
cases is so well known as to need no com- 
ment. 

Cardiac indications were present in 
twelve cases with one post-operative death. 
In advising cesarean section as a routine 
for the pregnant cardiac patient, it is my 
opinion that we are on strongly debatable 
ground. In recent years there has come to 
be a better understanding of heart disease, 
particularly from the functional aspect, and 
better cooperation between the internist and 
the obstetrician. Formerly the internist with 
the idea of “saving the patient the strain of 
labor” has all too frequently advised 
cesarean section as a means to this end, and 
this advice the obstetrician has been all too 
eager to accept. This has resulted in ill- 
advised operations in patients with broken 
compensation, with unnecessary deaths 
charged to cesarean section. The majority 
of pregnant women with heart disease can 
be delivered from below, often by forceps to 
prevent straining in the second stage, with 
far less risk, provided they have adequate 
prenatal cardiac supervision. Nor can we 
agree with the argument that abdominal 
section is preferable because it offers the op- 
portunity for sterilization. The problem of 
pregnancy may never again present itself if 
adequate birth control advice is given. If it 
does, pregnancy can then be interrupted in 
its early stage and sterilization done with a 
minimum of risk. 

It is agreed that the occasional cardiac 
woman should be delivered by cesarean sec- 
tion. These few cases are composed for 
the most part of those women whose de- 
compensation has been relieved, and who 
carry on to term, or near term, and again 
show evidence, in spite of treatment, of de- 
compensating before labor ensues; and of 
the cardiac with obstruction to labor, as in 
pelvic contraction, or obstructing fibroids. 

218 


Abruptio placenta was the indication for 
section in twelve instances. There were two 
deaths in this group, one from shock and 
hemorrhage, and one from peritonitis. 
Little comment is necessary on the treat- 
ment in this group. We believe that many 
cases with this major complication will con- 
tinue to be treated by cesarean section as 
the procedure of choice, inasmuch as the be- 
havior of the uterine musculature is unpre- 
dictable even, at times, with the abdomen 
open. 

The toxemias furnished indication for 
seventeen cases, nine of which were ne- 
phritic, six pre-eclamptic, and two eclamptic, 
occurring in the earlier years covered in this 
report. Three deaths resulted, all from 
toxemia rather than from operation. As 
a matter of record it should be stated that 
in one of the eclamptics a complicating fac- 
tor was placenta previa, in a primiparous 
patient not in labor. The literature and our 
own personal experience give ample proof 
that no worse results have been obtained in 
the treatment of the toxemias than by the 
routine resort to cesarean section, unless it 
be by the use of accouchement force. In our 
opinion section should be limited to the 
rapidly fulminating pre-eclamptics, which 
are few if the cases are under proper pre- 
natal supervision. 

For miscellaneous indications twenty-one 
cases were sectioned with no deaths. Uterine 
fibroids, large ventral hernia, large echino- 
coccus cyst of the ovary, double uterus, 
elderly primipara, all furnished cases. In 
addition multiple indications were found in 
a number of cases. 

Mortality — Maternal 

In the series of 338 cases, eight died, and 
absolute rate of 2.36 per cent. In trying 
to evaluate the danger of the operative pro- 
cedure itself it is seen that the cause of 
death was not surgical in four cases, viz., 
one with heart failure, and three from tox- 
emia, leaving four surgical deaths or a net 
rate of 1.18 per cent. Also in this group 
of 338 there is a consecutive series of 134 
without mortality, and a group of 164 clean 
cases, without vaginal examination, with 
intact membranes, not in labor or early in 
labor (comparable to the usual clean sur- 
gical operation), with one death, or .61 per 
cent. 

It would therefore seem that cesarean 

Jour. M.S.M.S. 


CESAREAN SECTION— SEELEY 


section in Detroit carries with it no more 
risk than the usual clean surgical case, pro- 
vided care is used to eliminate cases with 
doubtful indications or with contraindica- 
tions to abdominal delivery. 

In 1925 Welz reported a maternal mor- 


Morbidity 

The American Committee on Maternal 
Welfare has a criterion for estimation of 
morbidity, viz., a temperature of 100.4 de- 
grees or higher on any two postpartum days 
exclusive of the first twenty-four hours, 


TABLE III 


Case 

Age 

Para 

Indication 

Cause of Death 

1 

28 

I 

Aortic and mitral insufficiency 
Class III 

Myocardial failure 

2 

26 

I 

Abruptio placentae 

Peritonitis 

3 

27 

II 

Abruptio placentae 

Hemorrhage and shock 

4 

28 

I 

Nephritic toxemia 

Toxemia, 5th day 

5 

27 

I 

Pre-eclampsia 

Toxemia, 5th day 

6 

39 

I 

Pre-eclampsia 

Toxemia, 3rd day 

7 

35 

II 

Contracted pelvis 

Peritonitis, 5th day 

8 

22 

I 

Contracted pelvis 

Septicemia, 13th day 


tality of 13 per cent for cesarean section 
in this city. Five years later (1930) I was 
able to show a reduction in this rate to 4.43 
per cent. In the present series including 
the years 1928 to 1937, the absolute rate at 
Harper Hospital was 2.36 per cent. Inas- 
much as four deaths, early in the series, 
followed sections for indications which in 
the light of present knowledge we now 
believe to be questionable, and because death 
occurred as the result of these complications 
and not as a sequel of the operation, we 
may be able to predict a still further lower- 
ing of the mortality rate. (Net rate 1.18 
per cent.) 


Mortality — F etal 

TABLE IV 


Monstrosity 2 

Diabetes (mother) 3 

Cerebral hemorrhage 1 

Prematurity 6 

Thymic 1 

Congenital atelectasis 2 

Ruptured uterus 1 

Abruptio placentae 4 

Hemorrhagic disease 1 

Unknown 8 

Gross fetal mortality 29 — 8.5% 

Net fetal mortality 16 — 4.7% 


A total of twenty-nine infants did not 
survive, a gross mortality rate of 8.5 per 
cent. If deductions are made for nonviable 
prematures, monstrosities, and infants al- 
ready dead on admission (ruptured uterus 
one, abruptio placentae four, sixteen deaths, 
or 4.7 per cent, is the net rate. 

March, 1939 


with temperature readings at least four 
times daily, which has been quite generally 
accepted in this country. For our purposes 
we have used a somewhat more strict meas- 
ure and have classified as morbid any pa- 
tient with a temperature of 100.4 or higher 
at any one reading exclusive of the first 
twenty-four hours. By this criterion 193 
patients were morbid, or 57 per cent. The 
difficulties attending positive and accurate 
diagnosis of causes of puerperal morbidity, 
particularly when mild in character, are well 
known to all obstetricians. As well as this 
could be done is shown in Table V. One 
hundred sixty cases having low grade tem- 
perature for periods not exceeding three 
days were classified as puerperal endo- 
metritis. It is possible that a number of 
these temperatures if occurring after opera- 
tions in patients who were not pregnant, 
would be said to be “operative reactions.” 
Two definite cases of peritonitis occurred, 
both of whom died. Of the entire 193 pa- 
tients only thirty-three were morbid four 
days or more by our standard. It is inter- 
esting that there is no case in which breast 
complications were considered as a cause 
of morbidity. 

table v 


Endometritis 160 

Sepsis 11 

Wound abscess 5 

Parametritis 2 

Peritonitis 2 

Pneumonia 2 

Pyelitis 2 

Phlebitis 1 

Retained membranes 1 

Cause unknown 7 


Total 193 


219 


CESAREAN SECTION— SEELEY 


Further analysis shows that of the cases 
with ruptured membranes seventy-three 
per cent were morbid as compared to 55 
per cent in cases with unruptured mem- 
branes. 

A study of morbidity in relation to type 
of operation in cases with unruptured mem- 
branes shows that with the low cervical 
operation 51 per cent were morbid and with 
the classical operation 53 per cent. For the 
Porro operation the morbidity was 60 per 
cent. This would seem to show that there 
is very little difference, so far as morbidity 
is concerned, for cases with unruptured 
membranes, in the results of the two types of 
operation. Unfortunately a comparison of 
results with the low cervical and classical 
sections in cases with ruptured membranes 
is not available, as all in this group were 
done by the low cervical operation. 

In attempting to discover any differences 
in the morbidity rates for the two types 
of operations when the patient was in labor 
when sectioned we find that with the low 
cervical operation 50 per cent were morbid 
and with the classical operation 60 per cent 
were morbid. We were able to find no def- 
inite relation between the length of labor 
prior to operation and the number of days 
of morbidity. 

A comparison of the average morbid days 
shows three and one-third days for the low 
cervical, three and three-fourths for the 
classical, and three and one-half for the 
Porro operation. 

Summary 

An analysis of 338 cesarean sections done 
during a period of ten years at Harper Hos- 
pital shows a marked tendency toward the 
low cervical operation as the procedure of 
choice. 

If results in so far as mortality is con- 
cerned for the city of Detroit can be inter- 
preted in terms of those at a representative 


hospital, the rate of 13 per cent reported for 
1925 has been greatly reduced (2.36 per 
cent Harper) and still further reduction 
seems possible. A series of 134 consecutive 
cases without mortality, and a series of 164 
“clean” cases with one death (.61 per cent), 
with comparable results from many other 
hospitals, shows that, with proper selection 
of cases, risk from cesarean section is no 
greater than that from other clean abdom- 
inal operations. 

By a very rigid standard there is little 
difference in morbidity in clean cases not 
in labor and with unruptured membranes, 
between the low cervical and classical opera- 
tions. For cases in labor and with ruptured 
membranes the low operation is the proce- 
dure of choice. The average duration of 
morbidity is less with the low cervical opera- 
tion. 

Deaths occurred in four instances from 
causes not connected with operation and 
serve to emphasize the dangers in cardiacs 
and in patients with toxemia. 

Selected cases of placenta previa were 
sectioned in 43 instances without maternal 
mortality and with six fetal deaths from 
prematurity, which is as good a maternal re- 
sult, and probably a better fetal death rate 
than could have been obtained by more con- 
servative measures. 

The large number of patients for whom 
“previous section” was the indication for 
cesarean should emphasize the responsibility 
of the obstetrician advising the first section. 

References 

1. Campbell, James V. : Am. Jour. Obst. & Gynec., 33:451, 

1937. 

2. Daily, Edwin F. : Am. Jour. Obst., 30:204, 1935. 

3. Gustafson, Gerald W. : Surg., Gynec. and Obst., 64 : 

1035, 1937. 

4. Harris, L. J. : Canad. Med. Assn. Jour., 37:32, 1937. 

5. Phaneuf, Louis E. : Am. Jour. Surg., 35:447, 1937. 

6. Reekie and Kimball: Jour. Mich. State Med. Soc., 36: 

542, 1937. 

7. Seeley, W. F.: Am. Jour. Obst., 28:115, 1937. 

8. Seeley, W. F. : Am. Jour. Obst., 24:68, 1932. 

9. Welz, W. E. : Am. Jour. Obst., 13:361, 1927. 

10. Wilson, Karl M. : Am. Jour. Surg., 35:459, 1937. 


220 


Jour. M.S.M.S. 


AN IMPROVED NEEDLE FOR INTRAVENOUS THERAPY 
CONSTANTINE L. A. OD6N, M.D. 

MUSKEGON, MICHIGAN 

Since the introduction of Salvarsan, intravenous therapy has gradually come into gen- 
eral use. This has undoubtedly been due to the fact that a more definite and rapid effect 
of the drug can thus be had, than when administered orally. 

As a result of extensive research work carried on during past years in various private 
and commercial laboratories, a large number of therapeutic agents are now available for 
intravenous use, a factor responsible to some extent for the growing popularity of the 


method. 

Formerly, direct exposure of the vein was 
considered necessary in order to properly 
enter its lumen and in turn prevent infiltra- 
tion of adjacent tissues. But, as infection 
often followed and scars formed in situ, this 
method has gradually been abandoned, ex- 
cept for blood transfusions and occasional 
massive injection. This is especially true 
when frequent injections are advisable. 

The method of fixation of the vein with 
a cambric needle has also fallen into disre- 
pute. As a result of improvement in technic, 
the needle can now be inserted into the 
lumen of the vein with comparative ease and 
certainty, thus removing the former danger 
of infection, scars, and pain caused by ex- 
travenous infiltration. 

The experienced doctor encounters little 
or no trouble in its performance, but he must 
develop a technic suitable for the purpose. 
Unfortunately some never master the art, 
and their patients continue to have swollen 
arms. With a proper tourniquet in place, a 
peculiar sensation of a “give” is experienced 
when the needle enters the lumen. Without 
being able to detect or properly interpret this 
sensation, the needle may pass outside the 
wall of the vein or pass through both ante- 
rior or posterior wall, and not remain in the 
lumen. Absence of blood in the syringe bar- 
rel following aspiration is an indication of 
failure which must be corrected before the 
operation is continued. 

Equally important as manual dexterity is 
the selection of a proper needle. Needles 
varying from one-third to one inch, and 
from twenty to twenty-seven gage, should be 
kept on hand, always selecting the smallest 
gage suitable for each case. Too often too 
large a needle is responsible for failure. Ex- 
cept when a large quantity of a heavy fluid 
is to be given, I find the twenty-seven gage 



Fig. 1. This shows the advantage of the eccentric needle 
with syringe as compared with the older type for intravenous 
therapy. Note angle at which each penetrates the skin 
and enters vein. 

most suitable, as it causes less trauma and 
incidentally less pain to the patient. 

The needle point should be sharp and of 
correct angle. These are frequently not 
found on the average hospital tray, not be- 
cause of indifference on the part of the serv- 
ice room, but mainly because standardization 
of intravenous technic has never been prop- 
erly emphasized. 

I have long felt the need for improve- 
ment in intravenous needles. Several years 
ago, I designed a needle for intradermal use, 
consisting of a barrel three-fourths of a cen- 
timeter in length on a beveled shoulder, 
which permitted the needle to be promiscu- 
ously inserted into the skin with a skid-like 
manner. Its success in the intradermal field 
furthered the idea that the same principle 
could be applied to the needle for intrave- 
nous use. This resulted in the construction of 
a similar needle (Fig. 1) with a longer 
barrel which, when used with an eccentric 
syringe, has proven to be very satisfactory 
for the purpose intended. It insures an 
easier and more accurate entrance into the 
lumen of the vein, as it maintains a proper 
angle, and the position of the point is al- 
ways constant, thus minimizing the possi- 
bility of trauma to the vein wall or infiltra- 
tion of surrounding tissues. 


March, 1939 


221 



ONE YEAR OF OCCUPATIONAL DISEASE REPORTING 

IN MICHIGAN 


DON W. GUDAKUNST, M.D., Dr.P.H. 

State Health Commissioner 

KENNETH E. MARKUSON, M.D., C.P.H. 

Assistant Director, Bureau of Industrial Hygiene 

JOHN M. HEPLER, C.E. 

Industrial Hygiene Engineer, Bureau of Industrial Hygiene 
LANSING, MICHIGAN 

The first year of occupational disease reporting under the amended occupational disease 
reporting law* was brought to a close on November 1, 1938. This law provides that 
every physician, hospital superintendent or clinic registrar shall report to the State 
Health Department any case of occupational disease within ten days of its recognition. 
A total of 1,193 reports were received during the year, 1,008 of which were accepted as 
representing true cases of occupational diseases. 

This is a summary of the information obtained from these reports and an analysis 
of the compiled data by the source of re- 
ports, the race, sex and nativity of the pa- 
tients and the frequency of the reported 
diseases. 

Source of Reports 

Table I shows the geographical distribu- 
tion of the reports received and indicates the 
number of physicians by counties who have 
been responsible for these reports. It will be 
noted that only 34 of the 83 counties in 
Michigan have sent in reports of occupa- 
tional diseases and only seven counties have 
supplied more than ten reports. Genesee 
and Wayne counties together reported 807 
cases, or 80 per cent of the entire number 
received. Wayne county, including the city 
of Detroit, reported 400 cases or 39.7 per 
cent of the total. Some industrial counties 
such as Bay, Gratiot and Macomb have fur- 
nished no reports while Midland, Monroe 
and St. Joseph have been the source of only 
one report each. 

Over the entire state, 154 physicians con- 
tributed reports during the year. This num- 
ber represented only 2.5 per cent of the 
6,142 physicians listed for Michigan in the 
1938 American Medical Association direc- 
tory. It is recognized that many physicians, 
especially those in rural areas, did not see 
cases of occupational diseases during the 
past reporting period. Nevertheless, judg- 
ing from the experience of other states, at 
least five per cent of the registered physi- 
cians should have reported. During 1937, 
in the State of Ohio, where reporting has 
been in progress for many years, over eight 


TABLE I. DISTRIBUTION OF OCCUPATIONAL 
DISEASE REPORTS BY COUNTIES AND 
NUMBER OF PHYSICIANS REPORTING 

County 


No. of Cases 
Reported 

No. of 
Physicians 
Reporting 

Barry 


1 

1 

Berrien . . . . 


20 

3 

Calhoun . . . 


8 

4 

Cheboygan 


1 

1 

Delta 


1 

1 

Dickinson 


5 

2 

Emmet .... 


1 

1 

Genesee . . . 


407 

9 

Gogebic . . . 


2 

2 

Hillsdale . . 


2 

2 

Ingham . . . . 


3 

3 

Iron 


1 

1 

Isabella . . . . 


1 

1 

Jackson . . . 


1 

1 

Kalamazoo 


2 

2 

Kent 


40 

9 

Lapeer .... 


2 

1 

Lenawee . . 


5 

3 

Manistee . . 


2 

1 

Marquette . 


6 

4 

Mason .... 


1 

1 

Midland 


1 

1 

Monroe . . . 


1 

1 

Montcalm . 


1 

1 

Muskegon . 


10 

5 

Oakland . . . 


18 

4 

Ottawa . . . . 


2 

1 

Saginaw . . 


40 

7 

Shiawassee 


3 

2 

St. Clair . . 


13 

4 

St. Joseph . 


1 

1 

Van Buren 


4 

1 

Washtenaw 


2 

2 

Wayne (excluding 

Detroit) 42 

16 

Detroit 


358 

55 


*Act 210, Public Acts, 1937. 


34 Counties No. Reports 
Accepted. . 
No. Reports 
Rejected. . 
Total. . 


1008 

185 

1193 


154 


222 


Jour. M.S.M.S. 


OCCUPATIONAL DISEASE REPORTING— GUDAKUNST, ET AL 


TABLE II. DISTRIBUTION OF REPORTED OCCUPATIONAL DISEASES BY ETIOLOGICAL FACTOR 


(Number in parenthesis is item number in schedule of Workmen’s Compensation Act) 


County 

(2) Lead 

(12) Dope 

(14) Chrome 

(18) Miner’s Disease 

(22) Carbon Monoxide 

(23) Acid Fume 

(24) Petroleum Products 

(25) Blisters & Abrasions 

(26) Bursitis & Synovitis 

(27) Dermatitis 

(28) Hernia 

(30) Silicosis 

(31) Pneumoconiosis 

Pharyngitis 

n z; 
sr o 

eL rt ‘ Asthma 
c o 
ft* 3 

Sinusitis 

Total 

Barry 










1 







1 

Berrien 











1 

19 





20 

Calhoun 










7 


1 





8 

Cheboygan 



1 














1 

Delta 










1 







1 

Dickinson 












5 





5 

Emmet 










1 







1 

Genesee 

5 







211 

34 

128 

28 



1 



407 

Gogebic 












2 





2 

Hillsdale 










2 







2 

Ingham 







1 



2 







3 

Iron 










1 







1 

Isabella 










1 







1 

Jackson 










_ 1 







1 

Kalamazoo 





1 







1 





2 

Kent 

1 





1 


13 


14 

2 

2 

7 




40 

Lapeer 










2 







2 

Lenawee 





1 





4 







5 

Manistee 










2 







2 

Marquette 











5 

1 





6 

Mason 










1 







1 

Midland 















1 


1 

Monroe 










1 







1 

Montcalm 










1 







1 

Muskegon 








1 


3 


6 





10 

Oakland 

1 








9 

4 

3 

1 





18 

Ottawa 










2 







2 

Saginaw 



1 

1 




13 

7 

16 



2 




40 

Shiawassee 










2 

1 






3 

St. Clair 










3 


10 





13 

St. Joseph 










1 







1 

Van Buren 





1 





2 



1 




4 

Washtenaw 

1 









1 







2 

Wayne 

1 


1 


1 





8 


23 

7 



1 

42 

Detroit 

75 

1 



5 

1 


2 

16 

84 

63 

99 

12 




358 

Total 

84 

1 

3 

1 

9 

2 

1 

240 

66 

296 

103 

170 

29 

1 

1 

1 

1008 


per cent of the physicians submitted occupa- 
tional disease reports. 

Distribution of Case Reports by Disease 

The distribution of reported cases by dis- 
ease is presented in Table II. Only three of 
the 1,008 accepted reports did not appear on 
the schedule of the 31 diseases made com- 
pensable by the Workmen’s Compensation 
Law. The remaining 1,005 cases appeared 
under only 13 divisions of the schedule and 

March, 1939 


no cases were reported for the remaining 18 
divisions. 

Dermatitis and skin affections, including 
blisters and abrasions, accounted for 536 
cases or 53.2 per cent of all reports submit- 
ted. Next in order of frequency were sili- 
cosis with 170 cases (16.8 per cent) ; hernia, 
103 cases (10.2 per cent) ; lead poisoning, 
84 cases (8.3 per cent) ; bursitis and syno- 
vitis, 66 cases (6.5 per cent) ; and pneumo- 
coniosis, 29 cases (2.9 per cent). Each of 


223 


OCCUPATIONAL DISEASE REPORTING— GUDAKUNST, ET AL 


TABLE III. OCCUPATIONAL 0$ CAUSATIVE AGENT 
OF REPORTED CASES OF DERMATITIS 


Acid 6 

Brass 3 

Buffing 5 

Cement 7 

Chemicals (specified) 11 

Cloth Fabric 6 

Dyes and Dye Products 4 

Flowers and Bulbs 3 

Foodstuffs 10 

Ink 4 

Leather 1 

Metal 6 

Oil, Grease and Cutting Compounds 159 

Paint, Lacquer, Enamel, Varnish, Thinner 8 

Permanent Wave Solution 2 

Petroleum Products 28 

Plating 5 

Rubber Compounds 5 

Soap and Cleaning Compounds 16 

Sugar Manufacture 1 

Welding 1 

Wood 4 

Wood Alcohol 1 

Total 296 


the seven remaining disease classifications, 
including the non-scheduled group, was re- 
sponsible for less than one per cent of the 
total number of reported cases. 

The 23 agents or classes of agents re- 
ported as causing the 296 cases of occupa- 
tional dermatitis are listed in Table III. Oil, 
grease and cutting compounds gave rise to 
159 reported cases; petroleum products ac- 
counted for 28 cases; soaps and cleaning 
compounds 16 cases; chemicals (specified) 
11 cases and foodstuffs 10 cases. The re- 
maining 72 cases were distributed among 18 
causative agents. 

In most states, dermatitis and skin affec- 
tions have accounted for more than 60 per 
cent of all reported cases of occupational 
diseases. In Michigan, the rate was 53.2 
per cent for the year ending November 1, 
1938. Since this represents the first year of 
reporting in this State under the amended 
reporting act, the slightly lower percentage 
of dermatitis reports as compared with that 
of other states probably is not significant. 
The greatest single cause of dermatitis in 
industrial states where reporting has been in 
effect for some time is “soaps and cleaning 
compounds.” In this state, where mechan- 
ized industry is highly developed, the fact 
that approximately 54 per cent of the 296 
reported cases of dermatitis were caused by 
oil, grease and cutting compounds may be 
significant. 


Distribution of Cases by Race, Sex 
and Nativity 

An analysis of reported cases by race, sex 
and nativity of the patients is given in Table 
IV. The 1,008 reported cases include 688 
native white males, 245 foreign-born white 
males, 29 Negro males and 34 white fe- 
males. Approximately 60 per cent of the 
reports received for Negro workers were 
reports of silicosis, which suggests that Ne- 
gro labor is extensively used in the dusty 
trades. It should be noted, however, that 
the total number of reports received of oc- 
cupational diseases among Negroes is very 
small and there is reason to believe that 
many cases of occupational diseases in this 
group are not being reported. 

The high rate of silicosis among the for- 
eign-born white workers who have settled 
in Michigan may reflect their early exposure 
to silicious dusts in their native countries 
while employed as miners, quarrymen, stone 
cutters, et cetera. Undoubtedly, many for- 
eign-born workers were given employment 
in the dusty trades and similar occupations 
upon arrival in this country, and this also 
may contribute to the higher silicosis rate 
in this group. 

Distribution of Cases by Industrial 
Classification 

Table V indicates the distribution of re- 
ported cases of occupational diseases accord- 
ing to diagnosis and industrial classification. 
Seven hundred fifty-six or 75 per cent of all 
cases reported are charged to “transporta- 
tion equipment” which includes the manu- 
facture of automobiles, automobile bodies, 
parts, trucks, trailers, tractors, motorcycles, 
ships, wagons, et cetera; 112 cases are 
charged to the manufacture of “metallic 
mineral products”; 34 cases to “domestic 
and personal service”; 21 cases to “trans- 
portation” ; 16 cases to “food and allied prod- 
ucts”; and 15 cases to “mining and quar- 
rying.” The remaining 13 items in the 
classification, together with six cases of un- 
known industrial origin, account for 5.3 per 
cent of the reports received. 

Reports Not Acceptable 

As indicated earlier in this discussion. 185 
reports received during the year were re- 
jected. These reports did not contain suf- 
ficient information to warrant their accept- 
ance as representing diseases of occupa- 

Tour. M.S.M.S. 


224 


TABLE IV. OCCUPATIONAL DISEASES REPORTED BY SEX, RACE AND NATIVITY FOR STATE OF MICHIGAN 

October 29, 1937-November 1, 1938 


OCCUPATIONAL DISEASE REPORTING— GUDAKUNST, ET AL 


Unknown 

»-h i— < co co *— i 

O' 

Other Races 

Female 



Male 

CM 

CM 

Negro 

Female 



V 

13 

M- co co 00 

O' 

CM 

Foreign Born 
White 

Female 

- - 

CM 

JU 

13 

r-H »— < r-H f\J hH Tf". O' t'N r ~~ l 

M rH fO (VJ O' rH 

UG 

Native White 

I Female 


ro 

JU 

13 

't'-'co i O CM O' uo CM »— < CM 

M- WLON NLO^H 

CM CM 

688 

ALL CLASSES 


| Female 

H«0\H 

CM 

co 

Male 

fOHrOrtOOM>HOcO'tNO\0\cO 
00 co O O © O CM 

CM CMrtrt 

UG 

On 

Total 

00 ^ OOsONCM 

CM CM *—* i—i 

1008 | 

3SV3SICI 

(2) Lead Poisoning 
(12) Dope Poisoning 
(14) Chrome Poisoning 
(18) Miner’s Diseases 

(22) Carbon Monoxide 

(23) Acid Poisoning 

(24) Petroleum Products 

(25) Blisters & Abrasions 

(26) Bursitis & Synovitis 

(27) Dermatitis 

(28) Hernia 

(30) Silicosis 

(31) Pneumoconiosis 
Not Scheduled 

Total 


£ 

< 

O 


u 

£ 

o 

w 

H 

C 

H 

m 

W 

W 

H 

Pi 

O 

Ph 

in 

W 

3 

H 

V) 

P 

Q 

£ 


u 


>< 


H 

Pi 

O 

ft 

a 

« 

in 

W 

in 

< 

a 

m 

s 

a 

< 

£ 

o 

r— I 

H 

< 

ft 

U 

o 

o 


ai 

£ 

<u 

> 

o 

£ 

G 

CO 

O' 


as 

o 

o 

O 


* 


CO 

< 

W 

CO 

M 

Q 

< 

£ 

O 

l-H 

H 

< 

ca 

D 

u 

u 

o 


1 TOTAL 

IOOCMO 

r-H 

O LO (M 

LO 1-H 
»— < 

•nrOf^oON 

O' i— i "tO 

CM co 

1008 

NS 

1 ^ 




CO 

CO 

- 

O lo *-< 

CM 

-H 1-1 

29 

30 

| O' CM CM 

00 O 

U~1 

CO) —1 

, ct" co CD V) 

170 

28 

r-i 

On 


CM i-h 

CO 

o 

27 

CM CM CM 

CM CM M- CM 

i— CM 
CM 

i— i CM to H" 

tT 00 o 

»-H 

296 | 

26 


00 VO 
l o 

CM 


66 | 

25 

r-H 

CM 

- 


240 1 

Si 




^H 

r-H 

23 





CM 

22 




In ih 

O' 

00 

- 




- 

r-H 


CM 

- 


CO 


> 

05 

H 

CO 

p 

Q 

£ 


O 

PL, 
bo 

.S "O 


3 


•o 
o 
u 
CL 

2 jO.JJ 4) 

v- 3ft T *o 

2< S.2 

I'**"*, 

JJ bO'U JJ 

2 .£ S ‘-S *o 

E c <u x o 
I cm’ cd ^ 


c/i as 
• <u ft 

•at; 

• o 3 *- 
.•ft u.ti bo 
ft P cl, o 

• — u c-* w r- 

3 0, as 73 

^ C 3 A 

W _ .ft co i-l 

rt ^ _ 
ft <u o ^ 
a S u o 

So*U* 

O.U3 

c/) /=< • 

S-2 c o c 

22 oO- c 
d N od oi d 


c/> . 

' fcJ ft 

3 3 

O 

Ph 

v 
c 


co 


— — o , 

&J= * 
cL JS u 

0 1-1 
u"£¥ 

« tS^S- 

9* o rt • 
rt — o 

Ph W -K 


ft Q, 
o M 


rt 


cd 


f-4 V £ 

l«s 

H « g 
£ S-a 
^ ~ o O c 


rt o 

33 ft 

QJ C/l 

O C 
cn ca 


ONoO Q\ 


a 

< 

H 

o 

H 


March, 1939 


225 


Numbers at top of column refer to occupational diseases listed numerically in Table IV. 


OCCUPATIONAL DISEASE REPORTING— GUDAKUNST, ET AL 


tional origin. Examples of rejected cases 
are: cardiac enlargement, fracture, sacro- 
iliac strain, soreness, lameness, tender 
thumb, puncture wound, influenza, pleurisy, 
herpes zoster. 

The amended occupational disease report- 
ing act specifies that: “An occupational dis- 
ease, for the purpose of this statute, is an 
illness of the body which has the following 
characteristics: 

1. It arises out of and in the course of the 
patient’s occupation. 

2. It is caused by a frequently repeated or a 
continuous exposure to a substance or to a spe- 
cific industrial practice which is hazardous and 
which has continued over an extended period of 
time. 

3. It presents symptoms characteristic of an oc- 
cupational disease which is known to have resulted 
in other cases from the same type of specific ex- 
posure. 

4. It is not the result of ordinary wear and tear 
of industrial occupation or the general effect of 
employment or the kind of illness that results from 
contacts or activities in life outside of the patient’s 
occupational pursuits.” 

Comment 

It is evident that reporting of occupa- 
tional diseases in this state is far from com- 
plete. Furthermore, it appears that physi- 
cians are being guided unduly in their re- 
porting by the schedule of 31 diseases made 
compensable by a recent amendment to the 
Workmen’s Compensation Law; only three 
of the 1,008 acceptable reports did not cor- 
respond to the items on this schedule. Anal- 
ysis of the occupational disease reports re- 
ceived during this first year’s experience un- 
der the amended law leads to the following 
observations: 

(a) Some cases of occupational diseases known 
to the Department of Health have not been re- 
ported. 

(b) Some physicians have reported all disease 
states, including many of non-occupational origin. 

(c) Some physicians have reported only those oc- 
cupational diseases that led to loss of time from 
work. 

(d) Some physicians have reported only those 
occupational diseases that are compensable under 


another act providing compensation for selected 
occupational diseases. (Act 61, P. A. 1937.) 

(e) Some physicians, apparently, have properly 
reported all occupational diseases as defined by the 
reporting law. 

The prime purpose in reporting is to pro- 
vide information as to what occupational 
diseases occur in the state and under what 
circumstances they may arise. All diseases 
resulting from exposure to harmful sub- 
stances or conditions associated with any oc- 
cupation or industrial activity should be re- 
ported even though they may not appear on 
the present schedule of compensable dis- 
eases. The reporting of only those diseases 
found on the compensation schedule is not 
sufficient since information on the occur- 
rence of other occupational diseases in the 
state may lead to the addition of new items 
to the schedule. Furthermore, non-disabling 
as well as disabling diseases should be re- 
ported in order that this department may 
determine both the severity and frequency 
of occupational diseases occurring in the 
State of Michigan. 

The following suggestion is made in con- 
clusion: Any affection arising out of oc- 
cupation that will meet the definition of an 
occupational disease set forth in the amend- 
ed reporting act as quoted above should be 
reported to the State Health Department re- 
gardless of its presence or absence on the 
schedule of compensable diseases, the degree 
of disability it produces or the amount of 
lost time it incurs. 

For the convenience of all persons re- 
quired by law to report occupational dis- 
eases, several reporting forms were sent to 
all registered physicians known to be prac- 
ticing in the state at the time the amended 
reporting law became effective. In case these 
forms were not received, or the original sup- 
ply has been exhausted, additional blanks 
will be furnished upon request directed to 
the Bureau of Industrial Hygiene, Mich- 
igan Department of Health, Lansing or the 
Bureau of Industrial Hygiene, Department 
of Health, Detroit, Michigan. 


226 


Jour. M.S.M.S. 


STAFF CONFERENCE 


DEPARTMENT OF INTERNAL MEDICINE 
UNIVERSITY OF MICHIGAN 
STAFF CONFERENCE 


F. B., a retired farmer, aged seventy-two, was 
readmitted to the University Hospital on January 
11, 1939, complaining of pain in the right upper 
quadrant of the abdomen. He had been well until 
1929 when weakness developed insidiously and asso- 
ciated with this was ease of fatigue and vertigo. 
Dyspnea and palpitation caused a restriction of 
activities but after the progression of these symp- 
toms for three months, there was spontaneous im- 
provement followed by a relapse six months later. 
There was extreme pallor, a weight loss of 35 
pounds, and anorexia in addition to his previously 
experienced symptoms. He was given ventriculin 
for seven weeks following which he showed marked 
improvement, then the medication was discontinued. 
His course was uneventful except for intermittent 
soreness of his mouth and tongue until he acquired 
influenza in 1931, following which all of his symp- 
toms reappeared in addition to coldness and numb- 
ness of his fingers and toes. He had been having 
occasional attacks of moderately severe substernal, 
epigastric and right upper quadrant pain since 1929. 
These attacks were not related to exertion nor to 
his other symptoms, but appeared at any time and 
were accompanied by anorexia and occasionally by 
chills and fever. After two to three days he would 
again be free from this discomfort. 

He was first admitted to the University Hospital 
on October 30, 1932, after ventriculin and oral liver 
therapy had failed to induce a remission. At that 
time his findings were: T. 101° (F), P. 94, R. 24, 
and B.P. 122/64. He was an elderly man, rather 
poorly nourished, who appeared chronically ill. His 
skin was pale and slightly icteric. There was no 
peripheral edema. There was an arcus senilis with 
unequal sized pupils which reacted well to light and 
accommodation. There was moderate sclerosis of 
the retinal vessels. His mouth was edentulous, 
the tongue clean and smooth with obvious atrophy 
of the papillae. His chest was emphysematous but 
free from adventitious sounds. The heart was 
slightly enlarged but there were no abnormalities 
except a soft systolic murmur heard at the apex. 
The liver was palpable 6.5 cm. below the costal 
margin in the right mid-clavicular line. The edge 
was firm and smooth but not tender. The spleen 
was not palpably enlarged. The knee and ankle 
jerks were obtained; the vibratory sense was 
diminished over the legs and feet. There was no 
demonstrable Rombergism. 

There was no family history of any blood dys- 
crasia and the past history was non-contributory. 

Laboratory findings in 1932 : R.B.C. 1,500,000 per 
cu. mm.; W.B.C. 4,500 per cu. mm.; Hb. (Sahli) 
27 per cent (3.8 grams). Differential: Neutrophils 
59 per cent, small lymphocytes 17.5 per cent, large 
lymphocytes 16.5 per cent, eosinophils 1 per cent, 
monocytes 5.5 per cent, and blast cells 6.5 per cent. 
There was anisocystosis and poikilocytosis of the 
R.B.C. The Price-Jones curve indicated that very 
small and very large red blood cells were present, 
and that the largest percentage of them measured 
9.5 microns. The platelets were decreased in num- 
ber. The blood Kahn was negative. Blood bili- 
rubin 1.5 mgm. per 100 c.c. Gastric analysis after 
0.5 mgm. of histamin (hypodermically) showed an 
achlorhydria. The urine and stool examinations 
were negative. Electrocardiogram was not def- 
initely abnormal. 

Course in the hospital and after discharge : As 

March, 1939 


therapy he received weekly injections of intravenous 
liver extract. Following the first injection the 
reticulocytes rose to a maximum of 36.5 per cent 
five days later. There was marked symptomatic im- 
provement and at the time of discharge on No- 
vember 12, 1932, his blood showed 2,500,000 red 
blood cells per cubic millimeter, hemoglobin of 
37 per cent. For the past six years his blood has 
been maintained within normal limits by means of 
20 c.c. of intravenous liver extract at monthly 
intervals. During the first year he gained 30 pounds 
but has maintained his weight since then. 

When he was readmitted on January 11, 1939, 
he was having recurrent attacks of right upper 
quadrant abdominal pain with radiation to between 
the shoulder blades, associated with belching, flatu- 
lence, and occasionally vomiting. There were also 
rare attacks of precordial discomfort which radiated 
down the left arm. 

The physical examination was the same as in 
1932. 

Laboratory findings : R.B.C. 5,700,000 per cu. 
mm. ; W.B.C. 8,000 per cu. mm. ; Hb. 96 per cent 
(15.2 grams). Hematocrit 48 per cent. Mean cor- 
puscular volume 84 cubic microns. Blood bilirubin 
2.9 mgm. per 100 c.c. The electrocardiogram was 
not definitely abnormal. Roentgen-ray examination 
showed a normal upper gastro-intestinal tract and 
non-visualization of the gall bladder without evi- 
dence of stone. 

Discussion 

Dr. Cyrus C. Sturgis: Mr. B., do the injections 
you receive in the arm ever bother you? 

Patient : They seem to go to my head and cause 

dizziness for a few minutes. Once I had a chill 
after leaving the hospital. Occasionally I have a 
peculiar taste in my mouth. 

Dr. Sturgis : This patient brings up some very 

interesting points. First, about the treatment of 
pernicious anemia. In the present illness it states 
that ventriculin and oral liver extract failed to 
induce a remission. This occurs in only a small 
percentage of cases. As the oral therapy failed 
he has been given, for approximately six years, 
monthly intravenous injections of liver extract and 
these have maintained his blood within normal 
limits over that entire period. The intravenous 
method is not one that we recommend for routine 
treatment because occasionally it causes a reaction 
characterized by a peculiar taste in the mouth, 
dizziness, and severe chill followed by a febrile 
reaction. Although I have never seen any serious 
results from these, they may be disconcerting to 
both the patient and his physician. It has the ad- 
vantage, however, of maintaining the blood by giv- 
ing injections as infrequently as once a month. In 
general it can be said that the intramuscular injec- 
tion of liver extract is the treatment of choice, for 
the blood can be maintained at a normal level by 


227 


STAFF CONFERENCE 


giving injections at intervals of one to three weeks 
and they do not cause either a local or general re- 
action. This patient has some minor cord changes 
but in the six years that we have observed him 
these have not progressed. The important thing 
to accomplish is to maintain the blood at a high 
level of normal and keep the red blood cells normal 
in size. The last mean corpuscular volume deter- 
mination in this patient was 84 cubic microns, which 
is within normal limits. I think that when the blood 
count is just a little below normal, progression in 
cord changes may occur. 

In treating patients with highly purified and con- 
centrated liver extracts, it is entirely possible, but 
unproven, that one may be losing something in the 
refining process which has a desirable effect on the 
spinal cord changes. It must be said of this im- 
pression that it is lacking in definite proof. 

This patient, seventy-two years old, has had per- 
nicious anemia for six years or more ; if he con- 
tinues to do what we advise, he will not die of per- 
nicious anemia. I have just completed a study of 
120 records of our fatal cases who have been ob- 
served at the Simpson Memorial Institute in the last 
ten years. Approximately 10 per cent of our pa- 
tients, whom we hav.e observed during the past ten 
years, are dead. About one-half of the patients 
died of spinal cord changes or complications asso- 
ciated with them. Many had advanced spinal cord 
changes when we first observed them. A fairly 
large number failed to follow our directions in re- 
gard to therapy for it is difficult to take medicine 
when one has no complaints, and the symptoms of 
anemia do not appear until the red blood cell count 
falls below 3.5 millions per cu. mm. When the red 
blood cell 'count falls to this level or lower, there 
may be progression of cord changes. So far, I 
have never seen a patient with progression of spinal 
cord changes whose blood was maintained con- 
stantly at a high normal level. The remainder of 
the fatal cases died of various diseases, chiefly of 
the ones which are common in people of this age 
group, such as hypertension, congestive heart fail- 
ure, cancer, pneumonia and other conditions which 
are not directly related to pernicious anemia. It 
is interesting to note, however, that although many 
of these patients died of diseases which were only 
coincidentally associated with pernicious anemia, 
nevertheless most of them did not live out their 
normal life expectancy. 

This man has symptoms which might be due to 
coronary artery disease although we cannot prove 
this. The literature emphasizes the possible rela- 
tionship of angina pectoris and pernicious anemia 
but the two conditions have rarely been associated 
in our group of about 800 cases. When they do 
coexist, I think there must be an anemia plus 
some degree of narrowing of the coronary vessels 
and it is usually the combination of the two which 
gives the symptoms of angina pectoris ; an anemia 
alone could not cause it. It is entirely possible 
that this patient may have a cholecystitis or chole- 


lithiasis, as these conditions are not uncommon 
complications of pernicious anemia. 

Dr. Goldhamer, would you like to discuss this 
case? 

Dr. S. Milton Goldhamer: It seems to me that, 
while much time has been directed toward perfect- 
ing the treatment of pernicious anemia, more effort 
should be made to find out the etiology of per- 
nicious anemia. We have some information rela- 
tive to the physiology of the stomach which sug- 
gests a theoretical explanation. The majority of 
the patients with pernicious anemia are above the 
age of 45. Patients above this age normally may 
have an achlorhydria, so that it is conceivable in 
these individuals with pernicious anemia, in addi- 
tion to the above deficiency, they may have a “fail- 
ing stomach” whereby they do not make enough of 
the intrinsic factor. We also know that in people 
who do get pernicious anemia the gastric juice is 
markedly decreased and as the disease improves 
there is a partial return of function as evidenced 
by the increase in gastric juice volume. One in- 
dividual I studied for 90 days; as the blood count 
improved to normal, the average gastric juice 
volume increased to about 100 c.c. per hour from 
20 c.c. per hour. There is some effect on the func- 
tion of the stomach by the anemia as well as the 
stomach deficiency being a factor in the production 
of the anemia. This is also seen in pernicious 
anemia of pregnancy. We had a patient who had a 
red blood cell count of 900,000 per cu. mm., and 
with a high protein diet alone the anemia was alle- 
viated. It might be that the pregnancy causes the 
drop in the gastric juice secretion with a decrease 
in the intrinsic factor. We know that she had a 
deficient extrinsic factor because her diet was mark- 
edly low, and the combination of those two factors 
caused the anemia. 

We have a patient at present in whom we are 
unable to explain the reticulocyte response. She 
had a reticulocyte peak of 16 per cent with normal 
diet plus 90 grams of yeast. The vitamin B com- 
plex was removed before feeding. There was no 
response as far as the total blood count was con- 
cerned, in spite of the reticulocyte response. She 
gained 12 pounds in weight. Now we have put her 
on ventriculin and the reticulocyte response aver- 
ages about 11 per cent. The red cell count is grad- 
ually increasing but the patient is losing weight. 

Dr. Sturgis : This importance of the intrinsic 

factor in the gastric secretion in relation to the 
formation of red blood cells is a concept which has 
only been developed in recent years by W. B. 
Castle. There is no question about the accuracy 
of this work but it should be emphasized that a 
diminution, as well as an absence, of this factor is 
important in the causation of the anemia of perni- 
cious anemia. 

Another point in relation to the etiology of per- 
nicious anemia should be stressed. It is known that 
in a certain number of patients with pernicious 


228 


Tour. M.S.M.S. 


STAFF CONFERENCE 


anemia there is a reticulocyte response and a dis- 
appearance of the anemia following the feeding of 
large amounts of yeast which contains the extrinsic 
factor. Why some patients respond to yeast and 
others do not, we do not know. Is the great excess 
of extrinsic factor able to react with very small 
amount of the intrinsic factor? Would it be possi- 
ble to give a pernicious anemia patient some stim- 
ulant to increase gastric juice which would cause a 
beneficial effect? Would a substance which in- 
creases the secretion of hydrochloric acid likewise 
increase the amount of intrinsic factor? 

Dr. Henry Field, Jr. : Cord changes quite simi- 

lar to the cord changes in pernicious anemia pa- 
tients symptomatically can be produced in people 
by the deficiency of the vitamin B complex. We 
have discussed the adequacy of these highly purified 
yeast extracts. Elsom in Philadelphia reported 
some cases of pernicious anemia of pregnancy. Pa- 
tients on inadequate diets developed symptoms 
among which were those expected in cord changes 
in pernicious anemia, and the symptoms were re- 
lieved when they gave the whole vitamin B com- 
plex. I think we lack the concrete evidence on 
that. My curiosity was stimulated not only be- 
cause of the cord changes of pernicious anemia 
of pregnancy with vitamin B deficiency, but also be- 
cause of two patients that I have seen who had the 
cord changes with a secondary type of anemia — 
microcytic anemia. Both had achlorhydria and 
there has been experimental production of cord 
changes following a gastrectomy in certain animals. 
What the relationship is I do not know. 

The literature on posterolateral sclerosis de- 
scribes patients without pernicious anemia who have 
achlorhydria. 

Dr. Goldhamer: It is interesting to note that 

patients with pernicious anemia develop cord 
changes with loss of weight; yet, in patients with 
malignancy where the loss of weight is marked, 
they do not have any cord changes. 

Dr. Raphael Isaacs : The blood now shows a 

relative increase in polymorphonuclear neutrophils 
(86 per cent) with an increase in the number and 
percentage of monocytes (10 per cent). There is 
an unusual decrease in the number of lymphocytes 
(4 per cent of 8,000). The blood suggests involve- 
ment of the liver in the disease process, and 
pyogenic infection is present. The blood picture is 
not incompatible with a hepatitis, possibly secondarj 7 
to a gall-bladder lesion. 

Dr. Frank H. Bethell : The failure of this 


patient to derive the anticipated benefit from the 
oral administration of potent medication in dosage 
adequate for the majority of persons with perni- 
cious anemia suggests consideration of another fac- 
tor in the regulatory mechanism of hemopoiesis. 
This factor is the variable capacity of the intestine to 
absorb the hemopoietic substance. It is known that 
persons without evidence of gastric abnormality or 
diminished secretion of Castle’s intrinsic factor may, 
as the result of short-circuiting operations on the 
intestinal tract, jejuno-colic fistulas or prolonged 
diarrhea, develop severe macrocystic anemia ame- 
nable to parenteral liver therapy. It may reasonably 
be assumed that patients with true pernicious 
anemia may have their already limited capacity to 
develop red blood cells more severely restricted by 
relatively minor disturbances of digestion. The 
variations in dosage of oral preparations required 
for satisfactory maintenance of the red blood cell 
level in pernicious anemia, which are much greater 
than those of parenteral therapy, support this as- 
sumption. Of 69 patients observed at the Simpson 
Memorial Institute for a period of at least six 
months and receiving regularly the prescribed dose 
of ventriculin, extralin or oral liver extract, nine 
failed to attain a red blood cell level of 4,000,000 
and 34 showed persistent macrocytosis as evidenced 
by mean corpuscular volume values greater than 96 
cubic microns. Of 54 patients observed under com- 
parable conditions but treated with parenteral liver 
preparations, either by intravenous or intramuscular 
administration, and including the use of both con- 
centrated and dilute extracts, none failed to exceed 
a red blood cell count of 4,000,000 and in only six 
was the mean corpuscular volume above 96 cubic 
microns. 

Dr. Sturgis : Let me add just a few brief re- 

marks about the diagnosis of pernicious anemia. 
It is a disease which can be recognized with a great 
degree of accuracy if sufficient time is available for 
studying a patient. In addition to the symptoms 
and signs which are common to all the anemias, 
such as weakness, dyspnea, palpitation, pallor and 
occasionally edema of the ankles, there are seven 
other cardinal diagnostic points of the disease. 
These are (1) achlorhydria; (2) macrocytosis; 
(3) high color index ; (4) the response to patent 
anti-pernicious anemia therapy; (5) paresthesia; 
(6) recurrent glossitis ; and (7) leukopenia, or 
the absence of a leukocytosis. These are usually 
recognized or eliminated without difficulty; and, if 
all or even a majority of them are present, then the 
diagnosis of true Addisonian pernicious anemia is 
at once apparent. 


March, 1939 


229 


EDITORIAL 


THE JOURNAL 

OF THE 

Michigan State Medical Society 


PUBLICATION COMMITTEE 


A. S. BRUNK, M.D., Chairman Detroit 

F. T. ANDREWS, M.D Kalamazoo 

T. E. DeGURSE, M.D Marine City 

ROY H. HOLMES, M.D Muskegon 

J. EARL McINTYRE, M.D Lansing 


Editor 

J. H. DEMPSTER, M.A., M.D. 
5761 Stanton Avenue, Detroit, Michigan 


Secretary and Business Manager of The Journal 
L. FERNALD FOSTER, M.D. 

Bay City, Michigan 


Executive Secretary 
WM. J. BURNS, LL.B. 

2642 University Avenue, St. Paul, Minnesota 
or 

2020 Olds Tower, Lansing, Michigan 


MARCH, 1939 

" Every man owes some of his time to the up- 
building of the profession to which he belongs " 

— Theodore Roosevelt. 


EDITORIAL 

THE NATURE OF CANCER AND THE 
PHYSICIAN’S RESPONSIBILITY* 

/^ANCER begins as a local disease. It is 
characterized by atypical proliferation 
of the patient’s own body cells, producing a 
new structure which serves no useful pur- 
pose, has unlimited power of growth and is 
never self-healing. If it is discovered 
early, and removed or destroyed, cure is 
complete. If allowed to spread to essential 
organs or to produce distant foci through 

*The importance of early diagnosis as well as the insti- 
tution of early treatment, either surgical or x-ray, cannot 
be over-emphasized. This editorial is the first of a series 
on the subject written by a member and sponsored by the 
Cancer Committee of the Michigan State Medical Society. — 
Editor. 


transportation in the blood or lymph, cure 
may be impossible. 

For several years the Cancer Committee 
of the Michigan State Medical Society has 
been engaged in making these essential facts 
in regard to the nature of cancer available 
to the public. By press releases, feature 
articles, illustrated lectures and radio talks 
the message has been broadcast. The 
Women’s Field Army has now become such 
an important ally in this endeavor that it 
bids fair to assume the major burden of 
lay education. Dissemination of knowl- 
edge about cancer, its nature, early manifes- 
tations and its curability, has not created 
any new responsibilities for the physician, 
but has made it more imperative than ever 
before that he recognize and meet the social, 
economic and professional responsibilities 
which this disease has placed upon him. 
Some physicians who read this page will 
say that they have no interest in cancer, 
that they do not see cancer in their prac- 
tice. It is difficult to understand how any 
man with an active practice can fail to have 
frequent professional contact with malig- 
nant neoplasms. There are at least 25,000 
cases of cancer in Michigan today. There 
are probably 8,000 new cases each year, 
and each week about 100 deaths from can- 
cer are recorded in Michigan. Moreover, 
the increasing proportion of our population 
reaching the “cancer age” and the success 
in preventing and alleviating other diseases 
has created a greatly increased potential 
liability to cancer. These trends are still 
continuing and our responsibilities are in- 
creasing in magnitude each year. 

It is realized that the original responsi- 
bility for the early diagnosis of cancer rests 
with the patient. It is precisely for this 
reason that lay education is essential. The 
physician cannot initiate action. His client 
must come to him because of a mass, an 
abnormal discharge, a sore which does not 
heal, a new form of indigestion, a change 
in the bowel habit, or some other less fre- 
quent complaint. Whether asked or not, 
the question is always there. “What is it? 
Is this a sign, a symptom, of cancer?” And 
the patient is entitled to an answer without 
delay ! 

Thus the first responsibility of the phy- 
sician is that of securing prompt and def- 


230 


Jour. M.S.M.S. 


EDITORIAL 


inite diagnosis. The woman who has dis- 
covered a lump in her breast should receive 
professional service of a different quality 
than did the patient who was told by her 
family physician to come back in six weeks 
to see whether the lump had changed. For- 
tunately that patient herself knew that such 
advice was thoroughly bad and turned else- 
where for assistance. Not so the wife who 
took her husband from doctor to doctor 
seeking relief from his intractable “stomach 
trouble.” Not until the thirteenth physician 
was consulted, and after a loss of more 
than a year of valuable time, was the roent- 
genological study advised which revealed 
a then inoperable carcinoma. Delay in 
securing a diagnosis is added to the un- 
avoidable delay between the onset of the 

disease and the first medical consultation; 

- 

and delay frequently makes cure impossible. 

A statement so frequently reiterated 
tends to lose force, but it is still absolutely 
true that the fate of the cancer patient 
usually rests in the hands of the physician 
who sees him first. 

The second responsibility of the physician 
to the patient develops immediately upon 
making the diagnosis. Therapeutic man- 
agement must be mapped out. Everyone 
knows that the recognized methods of cur- 
ing cancer are removal by the knife or cau- 
tery and destruction by radium or x-rays. 
How these agents are to be used, and how 
they may be combined, may raise diffi- 
cult questions which require the collabora- 
tion of specialists. Treatment should be 
adequately conceived for the first attempt. 
A second opportunity to cure a cancer is 
seldom granted. 

There is a third responsibility which fre- 
quently must be borne alone by the family 
physician, and which makes a heavy draft 
upon his resources in both the art and the 
science of medicine. This is the care of 
the patient with incurable cancer. Much 
can be done in maintaining the general 
physical state, in mitigating pain and partic- 
ularly in sustaining morale. The writer 
has recently observed the final days of a 
patient with inoperable malignancy who 
kept up his professional and intellectual 
interests to the very end. It is possible to 

March, 1939 ' 


die of cancer courageously, and the phy- 
sician who is adequately meeting his respon- 
sibilities will help make this possible. 


SUPERVOLTAGE X-RAY THERAPY 

T"\ETROIT is soon to have an institute 
for the study and treatment of malig- 
nant disease. It is to be under the control 
of the medical department of Wayne Uni- 
versity. Just the extent of the venture, we 
do not at this time know. Chicago has its 
tumor institute which is well under way. 

The treatment of malignant disease opens 
up a vast field for study and research which 
can be carried on adequately only in such 
an institution of concentrated effort of pa- 
thologist, x-ray and radium therapist and 
physicist. To quote from the brochure sent 
out recently by the Chicago Tumor Insti- 
tute: 

“Although much progress has been real- 
ized during the last fifteen years in the ap- 
plication of x-rays and radium to cancer, 
our knowledge of the subject is still in its 
infancy. Those who have had the greatest 
experience with this problem are the first 
to recognize the limitation of our knowl- 
edge and the importance of exploring very 
thoroughly and very deeply the fundamen- 
tal principles of radiation and the techniques 
of its administration. The tendency to pur- 
sue a fixed technique in the radiation of all 
forms of cancer is to be avoided.” 

Dr. M. J. Hubeny, in a brief review of 
the progress of roentgenology, makes the 
following statement: “Supervoltage ther- 

apy, notwithstanding its widely heralded 
theoretical advantages, is still to be proved 
of sufficient value to warrant the installa- 
tion of the necessary apparatus.” He goes 
on to say, however, that close cooperation 
of groups, each consisting of a radiologist, 
special surgeons, pathologist and physicist, 
will after years of diligent observation, es- 
tablish the degree of its usefulness. 

The proposed institute in Detroit is in 
the right direction as the study and research 
feature is from the very nature of the prob- 
lem an institutional rather than a private 
function. 


231 


EDITORIAL 


DR. T. E. DeGURSE 

D R. T. E. DeGurse of Marine City, the 
newly appointed councillor for the sev- 
enth district, who succeeds Dr. Heavenrich, 
was born in Lambton County, Ontario, in 



Dr. T. E. DeGurse 

Councilor for the Seventh District of Michigan 

1873. He was educated at Assumption Col- 
lege, Sandwich, and the Detroit College of 
Medicine, where he was graduated in 1895. 
Dr. DeGurse has had a very busy career 
and he is in the truest sense an all around 
citizen. We can predict without reservations 
that the seventh councillor district will have 
an able representative in Dr. DeGurse, 
whose viewpoint is that of a physician in 
active practice of medicine. 

He served in Porto Rico during the Span- 
ish American War. He was health officer 
of Marine City for thirty years and served 
a year and a half during 1919-20 as full- 
time health officer in St. Clair. In 1927, Dr. 
DeGurse was appointed acting assistant sur- 
geon to the U. S. Public Health Service. He 
has practiced his profession in Marine City 
since his graduation, except his year in serv- 
ice in Porto Rico and his period as health 
officer in St. Clair as mentioned. He was 
for thirty years surgeon of the Rapid Rail- 
road and is at present local surgeon for the 
Bell Telephone, and Detroit Edison Com- 
pany, as well as Industrial Surgeon for 
Standard Products Company. Dr. DeGurse 
has been president of the St. Clair County 

232 


Medical Society on two different occasions, 
and from 1932 to 1938, he was alternate 
delegate to the American Medical Associa- 
tion. He is at present mayor of Marine City, 
where he was first elected in 1935. During 
Dr. DeGurse’s incumbency as mayor of Ma- 
rine City, his city has a filtration plant with 
a capacity of 2,500,000 gallons. During his 
incumbency as mayor, two fine parks have 
been laid out and landscaped. Dr. DeGurse 
has a winning personality, which, along 
with his ability, has attracted a large prac- 
tice. His experience and practical business 
outlook will be an asset to the Michigan 
State Medical Society. 


ON THE WITNESS STAND 

'"PHIS is the title of a brochure of sixty- 
four pages by J. Weston Walch, a lay- 
man who has studied the problem of medi- 
cal care from all angles. It has had a large 
circulation in the state of New York and 
by special arrangement with the medical 
society of the state of New York which 
holds the copyright, it is now available to 
the state of Michigan. Copies have been 
mailed to members of the Michigan State 
Medical Society under the sanction of the 
Public Relations Committee of the Society. 
As the number of copies procured is lim- 
ited, each doctor should peruse his bro- 
chure thoroughly and pass it on to appre- 
ciative laymen. We know of no clearer or 
more concise as well as truthful presenta- 
tion of the subject of socialized and in- 
dividualistic medicine. The method of 
presentation is that of question and an- 
swer; hence the title. There are 126 ques- 
tions completely and convincingly answer- 
ed. The answers are the result of consul- 
tation of numerous books and pamphlets 
as well as reports of foundations and com- 
mittees. The answers are also based on 
replies to questionnaires to governors, lo- 
cal and state health officers, college pro- 
fessors, hospital executives, as well as pri- 
vate physicians. 

The author has also written a book for 
young debaters in high schools and col- 
leges in which he presented both sides to 
the controversy in equal space. It will be 
remembered that a couple of years ago the 
subject of socialized medicine was one of 
much debate in the schools. In his book 


Jour. M.S.M.S. 



EDITORIAL 


he tried to be neutral. His study and as- 
sembly of the data soon convinced him that 
the people of the United States were on 
the whole healthier than those of coun- 
tries in which compulsory health insurance 
prevailed ; furthermore, that compulsory 
health insurance did not render satisfac- 
tory medical service. Since On the Wit- 
ness Stand was written, the report of the 
Surgeon-general of the United States 
Health Service has appeared. We have 
commented on it in the February number 
of this Journal. The satisfactory condi- 
tion of public health in this country is 
largely the result of patient prolonged, un- 
tiring efforts of the medical profession in 
apprehending disease in its early stages, 
rounding up infectious diseases and aiding 
quarantine. Every doctor practices and 
has practiced preventive medicine. Sanita- 
tion has also been an important factor, but 
without the practice of preventive medicine 
by the individual physician, organized 
health departments, civic or state, would 
be greatly handicapped. 

Read On the Witness Stattd and pass it 
on. It speaks for the physician more force- 
fully than he can speak for himself. 


CAMERA FANS’ HANDS 

If you are a camera fan and develop your own 
pictures, look at your hands! If there be a skin 
rash that resembles that from poison ivy, the possi- 
bility is that your developers may be the cause. 
At all times numbers of amateur photographers are 
wondering what may be the cause of a dermatitis 
on their hand;. The common cause may be found 
in the dark room. Among other developers are 
pyrogallic acid, metol, hydroquinone, amidol, rodinal 
and elon. Several of these substances are well 
known skin irritants. 

Experience is the best teacher but often the most 
expensive. The professional photographer long ago 
has learned the necessity of wearing gloves to avoid 
hand contact with some developers. The enthusias- 
tic amateur photographer needs to carry out the 
same precautions as the professional. Always wear 
rubber gloves when doing developing. If, for some 
reason, this is impractical, then rinse the hands after 
every contact with the developer. If a dermatitis 
appears only after the use of some one developer, 
avoid the use of this irritant and depend upon other 
types of chemicals. 

Dr. Carey P. McCord, Director of the Bureau of 
Industrial Hygiene of the Michigan Department of 
Health, states that in addition to skin diseases of 
the hands and forearms from developers, other skin 
diseases may arise among amateur photographers 
who utilize toning solutions containing salts of gold 
and platinum. Chromate solutions, as used in pho- 
tographic work, may produce typical “chrome holes.” 
These resist all treatment and may persist for 
months. Dr. McCord states that the ordinary 
brownish skin discoloration common to many pho- 
tographers who do their own developing is not par- 
ticularly important, but on occasion, this condition 

March. 1939 


may be followed by a painful, itching skin rash 
characterized by hundreds of small water blisters. 
When this skin rash appears, avoid all contact with 
developers. When fully healed, wear gloves during 
all developing work. Better still, let the professional 
photographer do your developing. 


OCCUPATIONAL CANCER 

The influence of occupation upon the occurrence 
of cancer among workers is a fact little realized by 
the general public, according to Dr. Carey P. Mc- 
Cord, Director of the Bureau of Industrial Hygiene 
of the Michigan Department of Health. The inci- 
dence of the disease, he says, is much larger among 
workers long exposed to such industrial substances 
as petroleum oils, coal tars, arsenic, aniline and shale 
oil, than among the general industrial population. 

The nation-wide system of compulsory reporting 
of occupational diseases in many European coun- 
tries has revealed large numbers of cancer cases. 
Great Britain reported 811 cases between 1920 and 
1927. In Europe high industrial cancer rates are 
found among workers engaged in chimney sweep- 
ing, briquette making, mining, mule spinning (a cot- 
ton spinning process), petroleum production and 
manufacturing and coal tar manufacturing and 
processing. In the United States greater mechani- 
zation of industry, improvement in industrial meth- 
ods of handling raw materials and by-products and 
a higher standard of working and living conditions, 
have cut down the occurrence of this disease among 
industrial workers, he believes. In Ohio, where re- 
porting has been required since 1913, only 11 cases 
have been recorded between 1920 and 1937. 

Even in the face of such favorable comparison, 
Dr. McCord feels that the problem of occupational 
cancer in Michigan warrants specific attention so 
that early diagnosis may be made and the contrib- 
uting factors identified. 


HAVE YOU EVER WORRIED ABOUT A 
DOCTOR’S HEALTH? 

“We called at the home of a doctor one evening 
recently. He had been out for several nights. Early 
in the evening the doctor had dropped sound asleep 
on a davenport in the living room — sleeping the 
sleep of the exhausted. We apologized and sug- 
gested that we would call another time . . . when 
the phone rang. He arose as in a trance and walked 
over to answer it. “Yes . . . yes . . . some tempera- 
ture? . . . well, I’ll be over right away.” 

Slowly he turned around. He stared at us, rub- 
bed his eyes, and said, “Hello, when did you come?” 
The man was hardly awake as he hustled into his 
hat and coat and with an apologetic “I’ll be back in 
a little while,” he left for the home of some sick 
person. 

Do you ever worry about your doctor’s health? 
That isn’t as ridiculous as it sounds. He may be 
rigid in his dictates about how you shall protect 
your health ; he may prescribe an exact routine 
which will prolong your years . . . but, he is abso- 
lutely and almost criminally careless about his own 
health. He has schooled himself to forget his own 
well being to protect yours. He jeopardizes the fu- 
ture of his own wife and children to watch over 
yours. 

“Yes,” you reply, “but isn’t he paid for it?” Is 
he? Doctors are short-lived. Their average expec- 
tancy of life is the lowest of the professional 
groups. They are valuable men in every commu- 
nity. We are not sure there is anything we can do 
about this but recognize it — and appreciate it. If 
socialized medicine and surgery becomes the rule, 
as some reformers would have it, we then would 
appreciate the family doctor.” — Lapeer County 
Press, Michigan. 


233 


POSTGRADUATE COURSES FOR 1939 

“A few physicians increase in knowledge from within and grow from their own 
doing. These are the innate investigators. The rank and file require outside 
help to grow and to progress. Books, meetings, contacts, discussions, teachers, 
are our armamentarium for progress. Like the ‘spring tonic’ of past days, all of 
us need some of this medicine at least annually, better if it comes more frequently. 
A large majority of physicians know their need and seek treatment.” — Henry A. 
Christian, M.D. 

Ann Arbor and Detroit 


Courses 


All dates inclusive 


Anatomy (Wednesdays) 

Electrocardiographic Diagnosis 

Pediatrics 

Urology 

Proctology 

Gynecology, Obstetrics and Gynecological Pathology 
Ophthalmology and Otolaryngology 
The Care of the Diabetic 

Diseases of Blood and Blood-Forming Organs 
Allergy 

General Practitioners’ Course 
Pathology: Special pathology of neoplasms 

Pathology of the female genito-urinary organs 
Special pathology of the eye 
Special pathology of the ear, nose and throat 
Laboratory Technic 
Summer Session Courses 
Roentgenology 
Roentgenology 

Neuropsychiatry (Administrators’ and Specialists’ Course) 
Neuropsychiatry (General Practitioners’ Course) 


February 15 — May 31 
April 3-8 
April 3, 4 and 5 
April 10, 11 and 12 
April 13, 14 and 15 
April 10-14 
April 20-26 
May 8, 9 and 10 
May 11, 12 and 13 
June 19-23 
June 26, 27 and 28 
June 26- July 7 
July 10-21 
July 24- August 4 
August 7-18 
June 26-August 4 
June 26-August 4 
June 26-August 4 
October 30-Nov. 4 
April 3 and 4 
November 1, 2 and 3 


EXTRAMURAL POSTGRADUATE COURSE 

Beginning April 3 and continuing throughout the month of April in the following centers: 

Ann Arbor Lansing- Jackson 

Battle Creek-Kalamazoo Saginaw 

Flint Traverse City-Manistee- 

Grand Rapids Cadillac-Petoskey 


Bulletin of postgraduate courses will be available shortly and will be sent 
upon request. 

DEPARTMENT OF POSTGRADUATE MEDICINE 
University Hospital, Ann Arbor, Michigan 


234 


Jour. M.S.M.S. 



President's Pace 


AUTONOMY 


There is considerable misunderstanding on the part of some mem- 
bers of our society as to the purposes of the Enabling Acts and of the 
objectives of the Medical Security Corporation. 

The thought and purpose is solely to make it legally possible for 
counties or communities to develop systems for the distribution of 
medical service on a voluntary prepayment basis strictly in accordance 
with their own local needs. 

The Michigan State Medical Society proposes to develop a central 
organization separate from the Michigan State Medical Society to 
assist, to advise and to aid local areas when requested. 

There is no intention of dictation or compulsion — I am unaware of 
any danger to your rights and prerogatives. 


Yours truly, 



President, Michigan State Medical Society 


March, 1939 


235 


♦ 


Department of Economics 

L. Fernald Foster, M.D., Secretary 


♦ 


THE NORTHWEST 
REGIONAL CONFERENCE 

About one hundred fifty representatives 
of the seventeen participating states and the 
American Medical Association met at the 
Palmer House in Chicago, Sunday, Febru- 
ary 12. The Conference, which meets an- 
nually, limits its discussions to questions of 
Medical Economics, 

The Conference decided to change its 
name, eliminating the geographical designa- 
tion now present. It also invited all state 
medical societies to become members of the 
participating group, which since its organi- 
zation, has been limited to those of the mid- 
western area. 

The Michigan State Medical Society was 
singularly honored at the 1939 Confer- 
ence when its President, Dr. Henry A. Luce 
of Detroit, discussed on the program, “The 
National Health Conference,” and when L. 
Fernald Foster, M.D., was elected president 
of the Conference for 1940, at which time 
the Michigan State Medical Society be- 
comes host to the meeting in Chicago. 


GROUP HOSPITAL SERVICE 

The Michigan Society for Group Hospi- 
talization, organized by the Michigan State 
Hospital Association and approved by the 
Michigan State Medical Society, has begun 
its operations in the field of hospital service. 

The organization will provide twenty-one 
days of hospital service in any one year on 
the following basis: 

Individual, 60c a month; husband and wife, $1.20 
a month; entire family (with all children from age 
one year to nineteen years) $1.50 a month. Service 
in semi-private room will be available at the follow- 
ing rates: Individual, 75c a month; husband and 
wife, $1.50 a month ; family, $1.90 a month. 

The hospital service will include no pro- 
fessional services rendered by a doctor of 
medicine. It will consist of room and board, 
general nursing, operating room and interne 
service, ordinary drugs and dressings and 
certain technical services rendered by hos- 
pital employes. 


COUNTY SECRETARIES’ 
CONFERENCE 

The Annual Conference of County Sec- 
retaries was held at the Olds Hotel, Lan- 
sing, Sunday, January 15. There was a 
large attendance of secretaries and guests 
present. The following topics and essayists 
made up the program. 

J. J. McCann, M.D., Chairman, presiding. 
“Greetings” — B. R. Corbus, M.D., President-elect, 
Michigan State Medical Society. 

“Michigan’s Group Hospital and Medical Care 
Plans.” — L. Fernald Foster, M.D., Secretary 
Michigan State Medical Society. 

“Our Legislative Forecast” — H. A. Miller, M.D., 
Chairman Legislative Committee, Michigan 
State Medical Society. 

“Affairs of State” — Hon. Vernon Brown, Auditor- 
General, State of Michigan. 

“Physicians in the Press and on the Aair” — Mr. 
Lee A. White, Public Relations Director, De- 
troit News. 

“The Duties of a 100 per cent County Secretary” — 
Mr. Joe Savage, Executive Secretary, West 
Virginia State Medical Society. 


REFUSING CALLS 

“Is a doctor of medicine legally compel- 
led to accept a call to render professional 
services?” 

This question has been asked frequently 
in the past, both by physicians and laymen. 

The Michigan State Board of Registra- 
tion in Medicine advises there is no law, 
state or federal, that can compel anyone to 
accept work or render services against his 
will so to do. This opinion has been backed 
by the Michigan Attorney General’s De- 
partment. 

“However, if a doctor of medicine ac- 
cepts a patient or promises to render serv- 
ices, he is responsible until such time as he 
discharges himself or is discharged by the 
patient, parent or guardian.” 


USE TAX 

Of interest to all physicians in Michigan 
is the following excerpt from a statement 
of the State Board of Tax Administration, 
which administers the Michigan Sales Tax 
and Use Tax: 

“As the Act is worded at the present time, all 
citizens and residents of this State are required to 

Jour. M.S.M.S. 


236 


DEPARTMENT OF ECONOMICS 


pay a tax upon their purchases where no sales tax 
has been paid. This ordinarily means upon all pur- 
chases made from outside of the State of Michigan. 
In so far as doctors, physicians and surgeons are 
concerned, it would require that they pay tax _ on 
all their equipment, such as bandages, surgical 
equipment, office equipment and also medicines for 
the use of their patients which they purchase from 
outside of the State of Michigan. We are not mak- 
ing any concerted drive against any particular group 
or class of taxpayers. All residents of this State 
are presumed to know that the law is in effect and 
we have endeavored to advise all of the various 
types of associations, such as doctors, dentists, con- 
tractors, merchants, civic organizations, fraternal 
organizations, etc., of their liability under this law, 
and if at any time we find the law being violated, 
we feel it is our duty to insist that the law be com- 
plied with.” 


GOVERNMENTAL MEDICINE 
OPPOSED 

The Pittsburgh Chamber of Commerce 
developed the following resolution which 
was forwarded to the President of the 
United States and all members of Congress 
from Pennsylvania: 

“The Pittsburgh Chamber of Commerce, whose 
civic program on public health work has brought 
it into frequent contact with the medical profession 
and its various associations, wishes to publicly ex- 
press its confidence in the principles and the pur- 
poses of the American Medical Association and the 
various affiliated medical groups that have been 
charged with violation of the Federal Anti-Trust 
Laws. 

“The Chamber of Commerce feels that organized 
medicine is not hostile to, or active against, any ade- 
quate plan for bringing medical and hospital service 
to the public at reasonable cost. We cite in support 
of this stand the current cooperation of the Alle- 
gheny County Medical Society with Pennsylvania’s 
Public Assistance Plan for Care of the Indigent 
Sick; its acceptance of group hospitalization insur- 
ance and its proposal to consider insured medical 
service for certain low income groups. 

“This Chamber, however, stands with the Alle- 
gheny County Medical Society and other medical 
associations in opposing centralized government con- 
trol through socialistic measures. We believe that 
such direction and control will prove extravagant 
and wasteful and is opposed to efficient service. It 
also tends to compete with current forms of medical 
practice and hospital service which are now under 
local and state sponsorship and is but another step 
toward un-American socialization of our accepted 
form of Government.” 


COUNCIL AND COMMITTEE MEETINGS 

1. Wednesday, February 8, 1939 — Legislative Com- 
mittee — Pantlind Hotel, Grand Rapids — 5:00 
p. m. 

2. Friday, February 10, 1939 — Maternal Health 
Committee — Hotel Olds, Lansing — 12:15 p. m. 

3. Thursday, February 16, 1939 — Advisory Com- 
mittee on Syphilis Control — Hotel Staffer, De- 
troit — 6 :00 p. m. 

4. Sunday, February 19, 1939 — Committee on Dis- 
tribution of Medical Care — University Hospital, 
Ann Arbor — 2 :00 p. m. 

5. Wednesday, February 22, 1939 — Medico-Legal 
Committee— Hotel Statler, Detroit — 4:30 p. m. 

March, 1939 


6. Wednesday, February 22, 1939 — Executive Com- 
mittee of The Council — Hotel Statler, Detroit — 
3 :00 p. m. 

7. Sunday, February 26, 1939 — Executive Commit- 
tee of The Council— Hotel Olds, Lansing — 
3 :00 p. m. 

8. Thursday, March 2, 1939 — Legislative Commit- 
tee — Hotel Statler, Detroit — 2 :00 p. m. 

9. Sunday, March 12, 1939 — Legislative Committee, 
Hotel Olds, Lansing — 3 :00 p. m. 


PROPOSED VOLUNTARY GROUP 
MEDICAL CARE BILL 

(House Bill No. 215) MICHIGAN 
A Bill Introduced by Representatives 
Dora Stockman, James B. Stanley and 
Warren G. Hooper, on February 20. 

To provide for and to regulate the incor- 
poration of non-profit medical care corpora- 
tions; to provide for the supervision and 
regulation of such corporations by the state 
commissioner of insurance ; and to prescribe 
penalties for the violation of the provisions 
of this act. 

Digest 

Section 1. — Intent of act: “to promote a wider 
distribution of medical care, and to maintain the 
standing and promote the progress of the .science 
and art of medicine in this state.” 

Section 2. — General purposes: Act permits for- 
mation of a corporation to establish, maintain, and 
operate a voluntary non-profit medical care plan 
whereby subscribers are entitled to medical and sur- 
gical care, appliances and supplies, in their homes, 
in hospitals, and in physicians’ offices. Such other 
benefits may be added from time to time as the cor- 
poration may determine. Plan is subject to super- 
vision by Commissioner of Insurance, but is not 
subject to Michigan laws with respect to insurance 
corporations or to the corporation laws. 

Section 3. — Manner of subscribing to articles of 
incorporation: (This section was drafted by the 
Insurance Department.) 

Section 4. — Fees which must be paid upon incor- 
poration. (Drafted by Insurance Department.) 

Section 5. — Plan to be submitted to Commissioner 
of Insurance for approval. (Drafted by Insurance 
Department.) 

Section 6. — Commissioner of Insurance may in- 
spect records of corporation. (Drafted by Insur- 
ance Department.) 

Section 7. — Annual Report shall be filed with the 
Insurance Commissioner. (Drafted by Insurance De- 
partment.) 

Section 8. — Board of Directors shall have repre- 
sentation from medical profession and the public. 

Section 9. — Corporation has authority to provide 
all medical benefits, but may divide benefits into 
classes or kinds, and limit same in quantity and to 
certain areas, (to permit experiments in a few sec- 
tions in order to develop the best possible plan.) 

Section 10. — Each M.D. has the right to register 
with the corporation to provide medical service. 
The physician-patient relationship shall be main- 
tained. No restriction shall be imposed on a doctor 
of medicine as to methods of diagnosis or treat- 
ment. 

Section 11. — Provision for reasonable reserves. 
Funds shall be invested only in securities permitted 
life insurance companies. (Drafted by Insurance 
Department.) 


237 


DEPARTMENT OF ECONOMICS 


Section 12 — Medical care shall be in accordance 
with the best medical practice in the community. 
“A non-profit medical care corporation shall not 
furnish medical care otherwise than through doc- 
tors of medicine.” 

Section 12 .— Payments in whole or in part may 
be made in behalf of indigent and borderline sub- 
scribers by corporations, associations, groups, in- 
dividuals, or governmental agencies ; but each con- 
tract shall be with the subscriber (the patient.) 

Section 14 . — Existing legal rights of the patient 
and the physician are not to be disturbed. 

Section 15 .— The corporation is not an insurance 
company but “is hereby declared to be a charitable 
and benevolent institution,” free from taxation. 

Section 16 . — Violation of provisions of act consti- 
tutes a misdemeanor. 

Section 17 . — Severing clause. 

The People of the State of Michigan Enact: 

Section 1. It is the purpose and intent of this act, 
and the policy of the legislature, to promote a wider 
distribution of medical care and to maintain the 
standing and promote the progress of the science 
and art of medicine in this state. 

Sec. 2. Any number of persons not less than 
seven, all of whom shall be residents of the state 
of Michigan, may form a corporation, under and 
in conformity with the provisions of this act, for 
the purpose of establishing, maintaining and oper- 
ating a voluntary non-profit medical care plan, 
whereby medical care is provided at the expense of 
such corporation to such persons or groups of per- 
sons of low income as shall become subscribers to 
such plan, under contracts which will entitle each 
such subscriber to definite medical and surgical care, 
appliances and supplies, by licensed and registered 
doctors of medicine in their offices, in hospitals, and 
in the home. Such other benefits may be added from 
time to time as the corporation may determine, with 
the approval of the commissioner of insurance. 
Medical care shall not be construed to include hos- 
pital service. 

Any such non-profit medical care corporation shall 
be subject to regulation and supervision by the com- 
missioner of insurance as hereinafter provided. Any 
such non-profit medical care corporation shall not 
be subject to the laws of this state with respect to 
insurance corporations or with respect to corpora- 
tions governed by the corporation laws, and no such 
non-profit medical care corporation may be incor- 
porated in this state except under and in accordance 
with the provisions of this act. 

Sec. 3. The persons so associating shall subscribe 
to articles of association which shall contain : 

First, The names of the associates, and their 
places of residence ; 

Second, The location of the principal office for 
the transaction of business in this state; 

Third, The name by which the corporation shall 
be known ; 

Fourth, The purposes of the corporation; 

Fifth, The term of existence of the corporation ; 

Sixth, The time for the holding of the annual 
meetings of the corporation; 

Seventh, Any terms and conditions of member- 
ship therein which the incorporators may have 
agreed upon, and which they may deem it import- 
ant to have set forth in said articles ; 

Eighth, Any other terms and conditions, not in- 
consistent with the provisions of this act, necessary 
for the conduct of the affairs of the corporation. 

Sec. 4. Such articles shall be acknowledged by 
the persons signing the same before some officer of 


this state authorized to take acknowledgments of 
deeds, who shall append thereto his certificate of 
acknowledgment. All such articles shall be in tripli- 
cate and upon proper forms as prescribed by the 
commissioner of insurance. Before said articles 
of association shall be effective for any purpose, the 
same shall be submitted to the attorney general for 
his examination, and if found by him to be in com- 
pliance with this act, he shall so certify to the com- 
missioner of insurance. Each corporation shall pay 
to the attorney general for the examination of its 
articles of association, or any amendments thereto, 
the sum of five dollars. Each corporation shall pay 
to the commissioner of insurance a filing fee for its 
articles of association, or any amendments thereto, 
the sum of ten dollars. Such fees shall be covered 
into the state treasury for the benefit of the gen- 
eral fund. 

Any corporation subject to the provisions of this 
act may, with the approval of the commissioner of 
insurance, and in the manner provided in its articles, 
amend its articles of association in any manner not 
inconsistent with the provisions of this act. 

Sec. 5. The persons so associating, before enter- 
ing into any contracts or securing any applications of 
subscribers, shall file in the office of the commis- 
sioner of insurance, together with triplicate copies 
of the said articles of association with the certificate 
of the attorney general annexed thereto, a statement 
showing in full detail the plan upon which it pro- 
poses to transact business, a copy of by-laws, a copy 
of contracts to be issued to subscribers, a copy of 
its prospectus, and proposed advertising to be used 
in the solicitation of contracts of subscribers. The 
commissioner of insurance shall examine the state- 
ments and documents so presented to him by the 
persons so associating, and shall have the power to 
conduct any investigation which he may deem nec- 
essary, and to hear such incorporators, and to ex- 
amine under oath any persons interested or con- 
nected with the said proposed corporation. If, in the 
opinion of the commissioner of insurance, the in- 
corporation or solicitation of contracts would work 
a fraud upon the persons so solicited, he shall have 
authority to refuse to license the said corporation to 
proceed in the organization and promotion of the 
association. If, upon examination of the said arti- 
cles of association, the documents and instruments 
above mentioned, and such further investigation as 
the commissioner of insurance shall make, he is 
satisfied that (a) the solicitation of subscriptions 
would not work a fraud upon the persons so so- 
licited; (b) the rates to be charged and the bene- 
fits to be provided are fair and reasonable; (c) the 
amount of money actually available for working 
capital is sufficient to carry all acquisition costs and 
operating expenses for a reasonable period of time 
from the date of issuance of the certificate of au- 
thority, and is not less than the sum of ten thou- 
sand dollars; (d) the amounts contributed as the 
working capital of the corporation are repayable 
only out of surplus earnings of such corporation, 
and (e) adequate and reasonable reserves to insure 
the maturity of the contracts are provided, he shall 
return to such incorporators one copy of such arti- 
cles of association, certified for filing with the 
county clerk of the county in which said corporation 
proposes to maintain its principal business office, and 
one copy to be certified by the commissioner of in- 
surance for the records of the corporation itself, 
and shall retain one copy for his office, files, and he 
shall deliver to such corporation a certificate of au- 
thority to commence business and issue contracts 
entitling subscribers to definite medical and surgical 
care, which contracts have been approved by him. 

The said commissioner of insurance shall have 
power and authority, at any time to revoke, after 

Jour. M.S.M.S. 


238 


DEPARTMENT OF ECONOMICS 


reasonable notice and hearing, any certificate, order 
or consent made by him to the said corporation, to 
proscribe applications for membership, upon being 
satisfied that the further solicitation of subscribers 
will work a fraud upon the persons so solicited, and 
he shall have authority to make such investigation 
from time to time as he may deem best, and grant 
hearings to such incorporators in their relation 
thereto. The commissioner of insurance shall have 
the same authority in respect to taking over and/or 
liquidating corporations formed and/or doing busi- 
ness under this act as is provided by chapter 3 of 
part 1 of Act No. 256 of the Public Acts of 1917, 
as amended. 

Any dissolution or liquidation of a corporation 
subject to the provisions of this act shall be conduct- 
ed under the supervision of the commissioner of 
insurance, who shall have all power with respect 
thereto granted to him under the provisions of law 
with respect to the dissolution and liquidation of 
insurance companies. 

Sec. 6. The commissioner of insurance, or any 
deputy or examiner or any other person whom he 
shall appoint, shall have the power of visitation and 
examination into the affairs of any such corporation 
and free access to all of the books, papers and docu- 
ments that relate to the business of the corporation, 
and may summon and qualify witnesses under oath, 
to examine its officers, agents or employes or any 
other persons having knowledge of the affairs, trans- 
actions and conditions of the corporation. The per 
diem, traveling and other necessary expenses in con- 
nection therewith shall be paid by the corporation. 

Sec. 7. Each such corporation shall annually on 
or before the first day of March of each year file 
in the office of the commissioner of insurance a 
sworn statement verified by at least two of the 
principal officers of said corporation showing its 
condition on the thirty-first day of December, then 
next preceding, which shall be in such form and 
shall contain such matters as the commissioner of 
insurance shall prescribe. In case any such corpo- 
ration shall fail to file any such annual statement 
as herein required, the said commissioner of insur- 
ance shall be authorized and empowered to suspend 
the certificate of authority issued to such corpora- 
tion until such statement shall be properly filed. 

Sec. 8. The board of directors of a non-profit 
medical care corporation shall have representation 
from the public and the medical profession of the 
state. 

Sec. 9. A medical care corporation may by its 
articles of association or its by-laws limit the bene- 
fits that it will furnish, and may divide such bene- 
fits as it elects to furnish into classes or kinds. In 
the absence of any such limitation or division of 
service, a non-profit medical care corporation shall 
be authorized to provide both general and special 
medical and surgical care benefits, including such 
service as may be necessarily incident to such medi- 
cal care. A medical care corporation may limit the 
issuance of contracts to residents of counties as 
specified by the by-laws. Any change in by-laws 
shall first receive the approval of the state com- 
missioner of insurance. 

Sec. 10. Each doctor of medicine, licensed and 
registered under Act No. 237 of the Public Acts of 
1899, as amended, practicing legally in this state 
shall have the right, on complying with such regu- 
lations as the corporation may make in its by-laws, 
to register with the corporation for general or spe- 
cial medical care, as the case may be. A non-profit 
medical care corporation shall impose no restric- 
tions on the doctors of medicine who treat its sub- 
scribers as to methods of diagnosis or treatment. 

March, 1939 


The physician-patient relationship shall be maintain- 
ed and the subscriber shall at all times have free 
choice of doctor of medicine. 

Sec. 11. A non-profit medical care corporation 
shall, before beginning business, and at all times 
thereafter while engaged in business, maintain re- 
serves in such form and amount as the commis- 
sioner of insurance may determine ; Provided, That 
the funds of any such corporation shall be invested 
only in securities permitted by the laws of this state 
for the investment of assets of life insurance com- 
panies. 

Sec. 12. All medical care rendered on behalf of 
a non-profit medical care corporation shall be in 
accordance with the best medical practice in the 
community at all times. 

A non-profit medical care corporation shall not 
furnish medical care otherwise than through doc- 
tors of medicine, licensed and registered under Act 
No. 237 of the Public Acts of 1899, as amended. 

Sec. 13. Each non-profit medical care corporation 
may receive and accept from governmental or pri- 
vate agencies, corporations, associations, groups, or 
individuals, payments covering all or part of the 
cost of subscriptions to provide medical care for 
needy and other persons. All contracts for medical 
care shall be between the medical care corporation 
and the person to receive such care. 

Sec. 14. No action at law based upon or arising 
out of the physician-patient relationship shall be 
maintained against a non-profit medical care corpo- 
ration. 

Sec. 15. Each corporation subject to the provi- 
sions of this act is hereby declared to be a charit- 
able and benevolent institution, and its funds and 
property shall be exempt from taxation by the state, 
or any political subdivision thereof. 

Sec. 16. Any person, or any agent or officer of 
a corporation, who violates any of the provisions 
of this act, or who shall make any false statement 
with respect to any report or statement required by 
this act, shall be deemed guilty of a misdemeanor, 
and upon conviction thereof shall be punished as 
provided by the laws of this state. 

Sec. 17. Should any provision or section of this 
act be held to be invalid for any reason, such hold- 
ing shall not be construed as affecting the validity 
of any remaining portion of such section or of this 
act, it being the legislative intent that this act shall 
stand, notwithstanding the invalidity of any such 
provision or section. 


KEEP YOUR STATUS AS PATIENT 

Socialized medicine has an intriguing sound. Per- 
haps the reason it attracts so many ears is because 
it sounds like medical treatment for nothing. Just 
at the present time we are getting so many things 
for nothing that business and others are being taxed 
to death. Within recent days some evidence bearing 
on socialized medicine was brought to Lansing from 
two widely separated points incidental to other dis- 
cussion. One point was the shore of Hudson bay, 
the other was Portland, Ore. Up in the sub-Arctic, 
a subsidized physician gave two Eskimo women, 
who needed serious attention, doses of castor oil. 
In Portland, Ore., a prepaid surgeon, who had no 
interest in his patient, sprinkled talcum powder over 
seriously-mangled fingers. As we proceed toward 
socialized medicine, let us consider it well . — Lansing 
State Journal, Feb. 18, 1939. 


239 


MID-WINTER MEETING OF TIJE COUNCIL 
January 28 and 29, 1939 




HIGHLIGHTS: 


1. Proposed enabling acts to permit voluntary group hospitalization and voluntary 
group medical care in Michigan, approved. 

Agreement reached with Michigan Hospital Association so that a comprehen- 
sive group health program may be offered to the public, upon enactment of en- 
abling laws. 

2. Annual Meeting, Grand Rapids, September 19, 20, 21, 22, to feature 38 eminent 
guest lecturers in 10 general assemblies. 

3. Secretary, Treasurer, Editor, Medico-Legal Committee, Executive Secretary 
elected. 

4. Budget for 1939 approved. 

5. Reports of numerous committees show amazing activity in behalf of better 
medical care and its distribution in Michigan. 


FIRST SESSION 

1. Roll Call . — The meeting was called to order 
by Chairman P. R. Urmston in the Hotel Statler, 
Detroit, at 10 :30 a. m. Those present were Drs. 
Urmston, Carstens, Huron, Barstow, Holmes, Sla- 
dek, Cummings, Andrews, Hart, Sherman, Haugh- 
ey, Moore, Hoffmann, and Brunk of The 
Council ; President Luce, President-Elect Corbus, 
Secretary Foster, Editor Dempster; Dr. Wm. J. 
Stapleton, Jr., Executive Secretary Burns. 

2. Minutes . — The minutes of The Council meet- 
ings of January 7-8 were read and approved. 

3. The Secretary’s Annual Report was read by 
Dr. Foster as follows : 

SECRETARY’S ANNUAL REPORT— 1938 

I herewith submit the report of the Secretary for 
1938. 

During 1938 the various activities of the Michigan 
State Medical Society were sustained and executed 
with unusual vigor. Members of the society con- 
tributed much time and energy to the solution of 
the many and ever increasing problems of organ- 
ized medicine. 

Membership 

The total paid membership for 1938 was 4,205, 
with dues of $49,192.00 accruing to the society. The 
number of physicians with unpaid dues at the end 
of 1938 was 115. The membership tabulation for 
the years of 1937 and 1938 showing net gains and 
losses, unpaid dues and deaths, is as follows : 

1937 1938 Gain Unpaid Deaths 

3,963 4,205 242 115 45 

There are approximately 4,700 potential members 
of the Michigan State Medical Society in the state. 
Memberships for 1938 would indicate that about 
500 eligible non-members exist at this time. This 
represents a decrease of 200 from the 700 non-mem- 
ber eligibles reported for 1937. 

In 1938, through the efforts of the county so- 
cieties and membership committee, 242 physicians 
were added to the membership rolls. This indi- 
cates an appreciation, on the part of these phy- 
sicians, of the benefits of membership in the State 
Society. I would estimate that the total member- 
ship for 1939 should be 4,350. 

MEMBERSHIP RECORD 


r 


County 1937 1938 

Branch 23 23 

Calhoun 119 118 

Cass 16 15 

Chippewa-Mackinac 23 23 

Clinton 11 10 

Delta 20 23 

Dickinson-Iron 23 24 

Eaton 29 29 

Genesee 155 155 

Gogebic 26 26 

Grand Traverse-Leelanau-Benzie 33 41 

Gratiot-Isabella-Clare ........ 35 40 

Hillsdale 26 25 

Houghton-Baraga-Keweenaw. . . 38 38 

Huron-Sanilac 29 26 

Ingham 134 139 

Ionia-Montcalm 38 40 

Jackson 91 . 97 

Kalamazoo-Van Buren 126 132 

Kent 227 236 

Lapeer 16 14 

Lenawee 40 44 

Livingston 19 17 

Luce 13 11 

Macomb 39 38 

Manistee 16 16 

Marquette-Alger 35 42 

Mason 10 12 

Mecosta-Osceola-Lake 17 19 

Menominee 17 13 

Midland 11 14 

Monroe 37 34 

Muskegon 77 82 

Newaygo 10 10 

Northern Michigan 31 31 

(Antrim-Charlevoix, 

Emmet, Cheboygan) 

Oakland 125 123 

Oceana 10 10 

O.M.C.O.R.0 14 17 

(Otsego, Crawford, Oscoda, 

Montgomery, Roscommon, 

Ogemaw) 

Ontonagon 6 8 

Ottawa 33 32 

Saginaw 96 94 

Schoolcraft 7 7 

Shiawassee 33 32 

St. Clair 47 51 

St. Joseph 15 19 

Tuscola 32 32 

Washtenaw 149 162 

Wayne 1,592 1,746 

Wexford-Kalkaska-Missaukee. . 23 22 


3,963 4,205 

3,963 

242 

Emeritus & Honorary Members... 
Paid Members 


o 

J 


_c 

C3 


T3 

"3 

c. 

s 

p 


1 - 4 3 

- - 1 

1 - - - 

3-1 
1-1 

- 11 1 

8 11 

5 2 1 

1 - - - 


3 


2 

2 

2 

1 


4 

3 


5 
2 

6 
6 
9 

4 


7 

2 

2 

3 

5 


1 - 

- 3 

- 2 
- 2 
2 1 
5 - 


2 - 

1 - 
- 1 

2 1 
- 3 

1 - 


2 - 8 2 
3 - - 


2 - - 

1 - - - 

2 - - 1 

1 - - - 

4-1 
4 — — 

13 3 1 

- 154 65 13 

1 - - 1 

28 270 115 45 

28 

242 

42 

. . . .4,205 




County 

1937 

1938 

o 

J 

o 

P 

1) 

a 

Allegan 

22 

24 

- 

2 

1 

- 

Alpena- Alcona-Presque Isle . 

18 

18 

— 

_ 

2 

— 

Barry 

15 

15 

— 

— 

— 

1 

Bay-Arenac-Iosco-Gladwin . . . 

71 

74 

— 

3 

2 

2 

Berrien 

45 

62 

- 

17 

2 

- 


Total 4,247 

Deaths During 1938 

During 1938 we regretfully record the deaths of 
the following members : 

Barry County — C. S. McIntyre, M.D., Hastings. 

Bay County — J. W. Hauxhurst, M.D., Bay City; J. R. 
Petty, M.D., Au Gres. 


240 


Jour. M.S.M.S. 


Deaths 


MID-WINTER MEETING OF THE COUNCIL 


Calhoun County — R. H. Steinbach, M.D., Wm. M. Dugan, 
M.D., of Battle Creek. 

Chippewa-Mackinac — C. J. Ennis, M.D., Sault Ste. Marie. 
Delta County — L. P. Treiber, M.D., Escanaba. 
Dickinson-Iron County — Joseph A. Crowell, M.D., Iron 
Mountain. 

Genesee County— W. G. Bird, M.D., Flint. 

Grand Traverse-Leelanau-Benzie County — Ernest B. Min- 
or, M.D., Traverse City. 

Gratiot-Isabella-Clare County — M. C. Hubbard, M.D., 
Vestaburg. 

Hillsdale County — D. W. Fenton, M.D., Reading. 

Ingham County — H. C. Rockwell, M.D., Lansing; C. F. 
Culver, M.D., Howell; R. M. Olin, M.D., East Lansing. 
Ionia-Montcalm County — Leon E. Duval, M.D., Ionia; A. 

I. Laughlin, M.D., Clarksville. 

Jackson County — Maitland N. Stewart, M.D.; S. W. 
Woyt, M.D., Jackson. 

Kalamazoo-VanBuren County — G. M. Braden, M.D., 
Scotts. 

Mason County — Frederick W. Heysett, M.D., Ludington. 
Monroe County - — S. O. Newcombe, M.D., Ida. 

Muskegon County — Frank Boonstra, M.D., J. G. Bowers, 
M.D., Muskegon; A. P. Poppen, M.D. 

Oakland County — John Bachelor, M.D., Oxford; J. O. 
Gaston, M.D., Rochester. 

Saginaw. County— Pearl S. Windham, M.D., Saginaw. 

St. Clair County — J. F. Martinson, M.D., Port Huron. 
Washtenaw County — George F. Inch, M.D., Ypsilanti. 
Wayne County — Claude G. Burgess, M.D., Robert E. 
Cummings, M.D., R. S. Dupont, M.D., Wm. A. Hackett, 
M.D., Henry J. Hartz, M.D., Hyde G. Warren, M.D., 
Charles A. Lenhard, M.D., Lewis S. Potter, M.D., Wesley 

J. Reid, M.D., Dayton D. Stone, M.D., A. B. Toaz, M.D., 
C. C. Wright, M.D., Detroit; R. C. Humphrey, M.D., 
Wyandotte. 

Wexford-Kalkaska-Missaukee County — H. C. Buster, M.D., 
Baldwin. 


Financial Status 

The fiscal year closed on December 24, 1938, and 
the statement of our certified accountants, Ernst & 
Ernst (published in the Journal), shows the finan- 
cial status of that date. The following facts are 
noted : 

1. The assets of the society are $43,821.55 as com- 
pared to $32,282.39 in 1937. The net worth is 
shown as $26,601.84, an increase, from the fig- 
ure of $11,764.39 of a year ago, of $14,837.45. 
Assignment of $3,500.00 to the Medico-legal de- 
fense fund would decrease the net worth by 
that amount and show an actual net worth in- 
crease of $11,337.45. This increase would just 
about represent the increase of dues and the 
profit from the annual meeting. 

2. The Medical Defense Fund shows a balance 
of $9,225.30 as compared to $12,048.60 of a 
year ago. This is a decrease of $2,823.30. No 
portion of dues was credited to the Medico- 
legal defense fund in 1938, although the sum 
of $3,500.00 was authorized for that fund. The 
securities assigned to this fund are now $12,- 
426.50. 

3. The Journal advertising sales in 1938 totaled 
$10,269.20 or an increase of $721.09 over 1937. 
The cost of printing The Journal in 1938 was 
$10,144.90, an increase of $179.86 over 1937. 
The net income of The Journal appears as 
$1,942.98, an increase of $736.13 over 1937. This, 
however, includes the allocation for subscrip- 
tions, which figure is $6,151.12. 

The increase in dues in 1938 partially restored 
the financial situation, which was somewhat de- 
pleted in 1937 by increased society activities. The 
continued increase in dues will scarcely maintain 
the situation in 1939, which forecasts increased 
operating expenses of rent, office personnel and 
enlarged committee activities. 

The 1938 Annual Meeting 

Another record attendance was broken at the 
Detroit Session. There was a physician attendance 
of 1,594, with a total registration of 2,077. The 
General Session type of Scientific program con- 

March, 1939 


DISTRIBUTION OF YOUR DUES DOLLAR 
1938 



tinued its interest appeal. The registrants were 
very generous in their attention to the technical ex- 
hibitors and developed an even greater goodwill 
among that group. In spite of a greatly augmented 
program of out-of-state speakers, with its in- 
creased expenses, the exhibits provided a substan- 
tial profit to the society. 

County Secretary Conferences 

Two County Secretary Conferences were held 
in 1938. One in Lansing on January 23, 1938, and 
one in Detroit September 20, 1938, on the occasion 
of the annual meeting. These conferences were ar- 
ranged . with a view to developing the County 
Secretaries as key men in their local groups. The 
attendance at the conferences was evidence of the 
interest on the part of the County officers in the 
programs of the State Society. 

Committees 

Each of the twenty-five committees of the state 
society performed its duties with despatch and ef- 
ficiency throughout the year. The constantly ex- 
panding program of the Michigan State Medical 
Society has made great demands upon the time and 
energy of all committemen, and they have ac- 
cepted their responsibility in a most creditable man- 
ner. 

Society Activity 

During the past year, your two secretaries have 
visited each of the fifty-four county societies at 
least once, and were usually accompanied by mem- 
bers of the Council, other officers and committee- 
men. Most of the components are well organized 
and active. In view of the many activities of a 
scientific and sociologic character, the county so- 
cieties, for the most part, are holding regular 
meetings and demonstrating an active interest in the 
affairs of the state society. 

During 1938 the Schoolcraft society was merged 
with the Delta county society. This affiliation has 
been of advantage to both groups. Late in 1938, was 
formed the Van Buren County Medical Society — a 
group of 32 former members of the Kalamazoo 
Academy of Medicine. 

The Speakers Bureau of the State society pro- 
vided eighty-eight speakers for county society meet- 
ings, the twenty-six speakers for lay groups, a 
total of 114 assignments. 


241 


MID-WINTER MEETING OF THE COUNCIL 


The Placement Service, which has been in op- 
eration two years, is receiving an ever increasing 
number of inquiries from both physicians and com- 
munities. 

The County Societies have been apprised of the 
state society's activities through the publication of 
sixteen secretary’s letters. Twelve of these were 
sent to county secretaries and four to the general 
membership of the Michigan State Medical Society. 
These communications also carried the items pro- 
mulgated by the Public Relations Committe and 
served as its bulletin. 

There were twenty-two State Society Night meet- 
ings held during 1938. During the past year, sev- 
eral county societies have instituted, through local 
educational institutions, classes in Public Speaking. 
These classes should help materially in providing 
more able .speakers, who can publicize the views 
and activities of the state society. 

Your secretary concludes his report with the 
following recommendations : that 

1. A sustained effort be made to interest every 
eligible physician in membership in his county 
and state society. 

2. The idea of State Society Night meetings be 
continued, but that, where possible, these be de- 
veloped as district or regional meetings, em- 
bracing several societies. 

3. The Speakers Bureau be developed with “Spot 
Speakers” throughout the state, each society 
assuming the responsibility of contributing per- 
sonnel to the bureau. 

4. The annual meeting program be continued as 
developed during the past two years — a pro- 
gram of General Sessions. 

Your secretary cannot express too sincerely to 
the council his appreciation of its fine cooperation 
and encouragement during the past year. All of 
the committees of the state society are to be com- 
mended for their splendid spirit, untiring efforts 
and successful execution of difficult tasks. To Ex- 
ecutive Secretary Wm. T. Burns for his inspiring 
enthusiasm, and to the office personnel for their 
willing and generous assistance, your secretary is 
truly grateful. 

Respectfully submitted, 

L. Fernald Foster, M.D., Secretary 
* * * 

The report was referred to the County Societies 
Committee. 


4. Treasurer’s Annual Report was presented by 
Treasurer Wm. A. Hyland as follows: 

TREASURER’S REPORT 

As Treasurer of the Michigan State Medical 
Society, I wish to submit the following report for 
the year 1938. 

As required by the by-laws of the society, the 
usual indemnity bond was filed with the state 
secretary. 

The bond committee (composed of Henry R. 
Carstens, M.D., Vernon M. Moore, M.D., and Wil- 
liam A. Hyland, M.D.) at a meeting in August de- 
cided to dispose of the Society’s New England 
Gas and Electric Co. bonds as soon as an oppor- 
tunity arises and a reasonable figure can be ob- 
tained. With this in mind, we are watching the 
market and expect to dispose of them sometime 
during the current year. 

The bonds have stood up very well during the 
past year — the present value is practically the same 
as a year ago. In addition, during November, I 
received a check for the National Electric Power 
Co. debentures in the amount of $262.79 and turned 
it over to the secretary, this being the first and 

242 


final distribution by the receivers of these deben- 
tures. 

The receipts for coupons for the securities for 
the year 1938 totaled $1,050, also dividend check in 
the amount of $14.40 from the National Gas and 
Electric Corporation .stock — making a total of $1,- 
064.40 which was forwarded to the secretary as 
usual. 

The total bond value of the Michigan State 
Medical Society, plus the dividends, the Receiver’s 
check of the National Electric Power Co. and 
credit of $93.98 at the Grand Rapids Trust Co. for 
exchange of bonds during 1937 but credited in 1938, 
brings the total Treasury value for 1938 to $30,- 
200.17. 

The following securities were held by the Mich- 
igan State Medical Society of the end of 1938 : 


general fund quoted market 

BONDS PRICE 

American Telephone & Telegraph Company $ 2,100.00 

Associated Gas and Electric Corporation 500.00 

Central Illinois Public Service Company 2,050.00 

Commercial Investment Trust Corporation 2,110.00 

Consumers Power Company 2,095.00 

Grand Rapids Affiliated Corporation 650.00 

New England Gas and Electric Company 527.50 

Standard Oil Company — New Jersey 1,050.00 

United Light and Power Company 2,080.00 

United States of America Savings Bonds 3,040.00 

Unclipped Coupons 150.00 


$16,352.50 

MEDICO-LEGAL DEFENSE FUND BONDS 

The Government of the Dominion of Canada due 

in 1945 $ 1,030.00 

The Government of the Dominion of Canada due 

in 1967 980.00 

Canadian Pacific Railway Company 1,570.00 

Detroit Edison Company 2,200.00 

Grand Rapids Affiliated Corporation 650.00 

New England Gas and Electric Company 527.50 

New York Central Railroad Company 1,360.09 

Southern Pacific Company 1,100.00 

United States of America Savings Bonds 2,660.00 

Unclipped coupons 25.00 


$12,102.50 

STOCK 

National Gas & Electric Corporation — common — 96 
shares 324.00 


$12,426.50 

$28,779.00 

Respectfully submitted, 

Wm. A. Hyland, M.D., Treasurer. 
* * * 

The report was referred to the Finance Commit- 
tee. 


5. The Editor’s Annual Report was presented by 
Dr. J. H. Dempster as follows : 

EDITOR’S ANNUAL REPORT 
“A year ago a request was made to keep The 
Journal within 100 pages a month, including adver- 
tising matter. To indicate how well this injunction 
was obeyed by the business office and the editor, 
the actual number of printed pages for 1938 was 
1,150. An endeavor has been constantly made to 
make The Journal reflect the attitude, editorially, 
of organized medicine in this state. I have written 
sixty editorials during the year, an average of five 
for each month. Of these, about forty discussed 
some phase of medical economics or medical sociol- 
ogy in its broader aspects. The department of County 
Activity conducted by the secretary and executive 
secretary have, besides editorial comment, pre- 
sented a faithful account of the deliberations of 
the council and the executive committee, as well as 
the discussions of the House of Delegates in the 
November Journal. Every member of the society 
has had an opportunity to familiarize himself with 
the work of organized medicine during the year. 
There were published 203 contributions on the scien- 
tific and clinical phases of medicine. This is 
due largely to the number of clinical histories 

Jour. M.S.M.S. 




MID-WINTER MEETING OF THE COUNCIL 


and short papers. We have encouraged the briefer 
contribution as distinct from that which aims at 
exhaustive discussion, owing to the fact that no 
magazine article, no matter what the length, can 
exhaust any subject. The briefer the paper, the 
greater the possibility that it will be read and not 
placed aside for that leisure that never comes to 
the average doctor. The demand for space men- 
tioned in other years is still as urgent as ever and 
can be met only by briefer contributions written 
with the greatest of care. A number of features 
conceived last year are included in the contents of 
the Journal the current year, notably the monthly 
clinical staff conference of the Department of 
Medicine of the University of Michigan and brief 
contributions from the Committee on Maternal Wel- 
fare of the Michigan State Medical Society. 

The editor expresses his appreciation of the as- 
sistance of the Publications Committee, the secre- 
tary and executive secretary and the publisher who 
has continued the excellence of former years in 
producing a journal that is typographically beyond 
reproach. 

All of which is respectfully submitted, 

J. H. Dempster, M.D., Editor. 

* * * 

The report was referred to the Publications 
Committee. 

6. The Annual Report of the Medico-Legal Com- 
mittee was presented by Dr. Stapleton and referred 
to the County Societies Committee, except that 
portion having to do with finances, which was re- 
ferred to the Finance Committee. 

7. Dr. I. W. Greene's letter was read by Dr. 
Luce; Dr. Greene recommended that someone be 
appointed in his place on the Executive Commit- 
tee. Motion of Dr. Cummings, seconded by several 
that a message from this council be sent to Dr. 
Greene wishing his continued improvement in 
health and that he will be able to serve the society 
in the future as in the past. Carried unan. 

The Chair appointed Dr. Haughey as Acting 
Chairman of the County Societies Committee. 

8. Special Committee on Changes in Medico- 
Legal Activity. Dr. Andrews reported that the com- 
mittee had met with Attorney Payette, and he read 
his legal opinion. The report was referred to the 
County Societies Committee to discuss with the 
Special Committee and with Dr. Stapleton. 

9. Other Committee Reports: 

(A) Legislative Committee: 

(a) The proposed amendments to the prenup- 
tial physical examination law were approved on 
motion of Dr. Haughey, seconded by several and 
carried unanimously. 

(b) Report was given on conference of Dr. 
Ramsey and Mr. Brown re amendments in the 
Afflicted Child Law. 

(c) Report on proposed welfare laws was 
presented. 

(d) Dr. Luce reported on meeting in Wash- 
ington, D. C. of the Committee of Seven : All 
phases of the proposed National Health Plan 
were approved in principle, except compulsory 
health insurance ; however, it was felt that the 
same type of service could be rendered without 
expending so much money. 

(e) The bill sponsored by the Waterworks 
Operators was approved as a worthy public health 
measure on motion of Drs. Carstens-Hart. Car- 
ried unanimously. 

(f) State Accident Fund case was discussed. 
Motion of Drs. Carstens-several that this mat- 
ter be referred to the Chairman of The Coun- 
cil, the Secretary and Executive Secretary for a 

March. 1939 


fuller investigation and report at the next meeting 

of the Executive Committee. Carried unanimously. 

(B) Mental Hygiene Committee: Report was 
read by Dr. Hoffmann. Referred to Finance Com- 
mittee. 

(C) Preventive Medicine Committee: Report was 
read by the Executive Secretary. To Finance Com- 
mittee. Motion of Drs. Hart-Andrews that the 
recommendations re typhoid be approved. Carried 
unanimously. 

(D) Public Relations Committee: Report read 
by Dr. Foster. To Finance Committee. 

(E) Membership Committee report was pre- 
sented. To Finance Committee. 

(F) Radio Committee report was presented and 
discussed. Motion of Drs. Holmes-Haughey that 
this be referred back for additional information. 
Carried unanimously. 

(G) Liaison with Hospitals: Report was read. 

(H) Cancer Committee report was read. The 
Sub-committee is to be discussed at a later ses- 
sion of The Council. Budgetary item to Finance 
Committee. 

(I) Joint Committee: Report read by Dr. Corbus. 
Budgetary item to Finance Committee. 

(J) Committee on Scientific Work presented by 
Dr. Foster, who urged the Councilors to explain the 
merits of the Technical Exhibit to detail men. 


10. The Publications Committee report was read 
by Dr. Brunk, as follows : 

REPORT OF THE PUBLICATIONS 
COMMITTEE— 1938 

You have heard the editor’s annual report. Early 
in the year (1938), a questionnaire was mailed to 
the members of the Michigan State Medical So- 
ciety, for the purpose of ascertaining the attitude of 
the members, to The Journal. Over 300 replies 
were received, which we presume to be a cross- 
section of opinion of the membership. Replies have 
been tabulated, together with comments, which ac- 
companied them, and have been published in the 
October number of The Journal. You have, 
doubtless, read the article. Many suggestions were 
made and of these, a large number either were in 
effect at the time, or have since been carried out. 
Some, of course, are conflicting. For instance, one 
number calls for more articles on the business side 
of medicine; another states, “There is no such 
thing as the business side of medicine.” Obviously, 
where opposite requests are made, it is impossible 
to satisfy all. Some would prefer The Journal. 
printed on paper that is not glossy, claiming that 
it would be easier to read, and some call for more 
illustrations. The fine calendered paper is neces- 
sary for the fine half-tones. It would be impos- 
sible, for instance, to print photomicrographs on 
coarse paper. Many expressed entire satisfaction 
with The Journal, and a surprising number de- 
clared that they read The Journal through from 
cover to cover. Among the questions asked was, 
“Do you fill out sample coupons?” Forty-seven re- 
plied in the affirmative ; fifty-seven in the negative ; 
and thirty-five said, occasionally. We draw atten- 
tion to the fact that The Journal is only possible 
from the dollar and a half appropriated from the 
annual dues, and the sale of advertising. An effort 
has been made to include in The Journal only high- 
grade ethical advertising. This is your Journal, 
and its continuance and enlargement will depend 
largely on the advertising patronage, and that, in 
turn, depends upon the extent to which the mem- 
bers of the society patronize the advertisers. 

It is almost trite to say that we are living in 
changing times, an era of rapid transition. This 
calls for more than ordinary editorial judgment. 


243 


MID-WINTER MEETING OF THE COUNCIL 


if something does not appear as permanent record, 
that will not eventually call for a change of atti- 
tude. We feel that the editor has sensed this fact 
and has therefore avoided extravagant statements 
or positive assertion where such is not warranted. 
The Journal, each month, has presented the de- 
liberations and conclusions of the Executive Com- 
mittee of the Council, so that each reader has 
had the opportunity of following, from month to 
month, the work of this managing committee. The 
President’s Page has afforded him, each month, an 
outlet for his personal message to the profession 
as a whole. This is a feature that is highly com- 
mendable and, therefore, of survival value. 

Respectfully submitted, 

A. S. Brunk, M.D., Chairman 
F. T. Andrews, M.D. Roy H. Holmes, M.D. 

T. E. DeGurse, M.D. J. Earl McIntyre, M.D. 

* * * 

The report was referred to Publications Commit- 
tcc. 

Recess : 12 :30 P.M. 

SECOND SESSION 

11. The Council reconvened at 3:30 p.m. In ad- 
dition to those present at the first session, the fol- 
lowing were present : Drs. DeGurse, McIntyre, Riley 
and Hyland. 

12. Additional Committee Reports: 

(K) Postgraduate Committee: Report by Dr. 

Cummings, who asked for suggestions from all pres- 
ent. Budgetary item to Finance Committee. 


13. Reference Report of Committee on County 
Societies was read by Dr. Haughey, as follows : 

REFERENCE REPORT OF COMMITTEE 
ON COUNTY SOCIETIES 

(a) Secretary’s Report was read and discussed. 
This Committee suggests that the Executive Office 
send a list of members of the MSMS as of Janu- 
ary 1, 1939, by county, to the County Secretaries, 
and ask the secretary of the County Society to add 
the names of any other physicians in the county 
which are not listed, and to give the reasons why 
they are not members. 

The Committee recommends that the County Sec- 
retaries make prompt notification of deaths, re- 
movals and changes of status of their members, 
to the Executive Office. 

The Committee recommends that the County Sec- 
retaries’ Conference (one in January and one at the 
time of the Annual Convention) be continued. We 
also recommend that a mid-winter meeting of the 
Secretaries of the Upper Peninsula County Medical 
Societies be held at a suitable time and place, and 
that at least one of the State Secretaries attend. 

The Committee feels that the suggestion of writ- 
ing letters to Congressmen and having a definite 
plan of what to write, is excellent. 

The Committee recommends that more county so- 
ciety reports should be published in The Journal 
and that these reports should be made more inter- 
esting and not so brief as in the past. 

The Committee wishes to compliment the Secre- 
tary upon his excellent and comprehensive report. 

(b) . Medico-Legal Report was discussed. The 
Committee adopted the following resolution : 

Whereas, we may be assessed a high rate of taxa- 
tion on account of operation of the MSMS Medico- 
Legal Defense, and 

Whereas, attorneys tell us that the only way we 
•can be free from paying these taxes is to discon- 
tinue this activity, and 

Whereas, a large majority of the members of the 
MSMS carry their own defense insurance, 

This Committee recommends that the House of 


Delegates at its next session (special or regular) 
amend the by-laws as suggested by our attor- 
ney so as to eliminate the offering of defense as a 
part of the benefits of membership in the Michi- 
gan State Medical Society. 

We further suggest that the Medico-Legal Com- 
mittee (to be known as the “Grievance Commit- 
tee”) be retained as a standing committee of the 
State Society, but that the details of its activities 
be turned over to the Executive Office in Lansing. 

We also recommend that the funds which have 
been set aside for medical defense be retained in 
this fund to care for cases, the cause of action for 
which shall have arisen previous to the termination 
of this feature of our work, and any balance to be 
transferred to the general fund. 

Respectfully submitted, 

Wilfrid Haughey, M.D., Acting Chairman 
C. D. Hart, M.D. 

W. H. Huron, M.D. E. F. Sladek, M.D. 

* * * 

The first part of the report re the Secretary’s 
Annual Report was approved on motion of Drs. 
Haughey-Hart. Carried unanimously. 

The second part of the report re Medico-Legal 
Activity was thoroughly discussed by The Council. 
Motion of Drs. Huron-Cummings that the last 
paragraph, having to do with the disposition of the 
Medico-Legal Fund, be referred back to the Special 
Committee on Changes in Medico-Legal Activity, 
to obtain exhaustive legal opinion on same. 

The balance of the report was accepted as read. 
Carried unanimously. 


14. Reference Report of Committee on Publica- 
tions was read by Dr. Brunk, section by section. 

REFERENCE REPORT OF PUBLICATIONS 
COMMITTEE 

Your Committee on Publications met and respect- 
fully recommends to The Council : 

1. That the Editor’s Report and Publications 
Committee Report be approved and that Dr. Demp- 
ster be commended for his efforts, motion of Drs. 
Sherman-Andrews. 

2. That the Editor do not accept over one and 
one-half pages each from the State Department of 
Health and the Woman’s Auxiliary for publication 
in The Journal each month, motion of Drs. Holmes- 
Andrews. 

3. That the color of the cover of The Journal 
be changed each month, motion of Drs. Holmes- 
Andrews. 

4. That The Council offer individual advertis- 
ing solicitors a commission on new advertising ob- 
tained for The Journal, motion of Drs. Andrews- 
Holmes. Dr. Foster and Mr. Burns are to discuss 
this matter with Will Braun and H. L. Sandberg 
of the A.M.A. in Chicago on February 11. 

5. That the suggestions of the Publishing Com- 
pany be accepted and envelopes for The Journal 
be eliminated, saving $150 per year, motion of Drs. 
Andrews-Holmes. 

Respectfully submitted, 

A. S. Brunk, M.D., Chairman 
F. T. Andrews, M.D. T. E. DeGurse, M.D. 

R. H. Holmes, M.D. G. A. Sherman, M.D. 

* * * 

SOCIETY BUDGET FOR 1939 

INCOME: 

4,200 members at $12 

(less Yi and l A dues of new members) $ 49,400.00 

Interest 700.00 

Total income $ 50,100.00 

Less allocation to The Journal at $1.50.. 6,300.00 

Total Net Income $ 43,800.00 

Jouk. M.S.M.S, 


244 


MID-WINTER MEETING OF THE COUNCIL 


APPROPRIATION S : 

Administrative and General: 

Medical Secretary Salary $ 2,400.00 

Executive Secretary Salary 7,000.00 

Other Office Salaries 5,820.00 

Extra Office Help 900.00 

Office Rent and Light 1,284.00 

Printing, Stationery, Supplies 1,000.00 

Postage 800.00 

Insurance and Fidelity Bonds 190'.00 

Auditing 250.00 

New Equipment and Repairs 300.00 

Telephone and Telegraph 500.00 

Legal 750.00 

Miscellaneous 175.00 


Total Admin, and General $ 21,369.00 

Less Journal office expense 1,800.00 


$ 19,569.00 

Society Expenses : 

Council Expense $ 3,000.00 

Delegates to A.M.A 800.00 

Secretaries Conferences 850.00 

General Society Travel Expense 2,000.00 

Secretary’s Letters 500.00 

Publications Expense 500.00 

Reporting Annual Meeting and Special Session 275.00 

Education Expenses 3,000.00 

Sundry Society Expenses 750.00 

Organizational Expense 3,000.00 

Contingent Fund 1,331.00 


Total Society Expense $ 16,006.00 

Less gain from Annual Meeting 1,500.00 


Net Society Expense $ 14,506.00 

Committee Expenses : 

Legislative Committee $ 3,500.00 

Com. on Distribution of Med. Care 2,000.00 

Cancer Committee 250.00 

Preventive Medicine Committee: 

(Including Adv. on Syphilis and Adv. on 

Tuberculosis Control) 200.00 

Radio Committee 25.00 

Postgraduate Medical Education 1,400.00 

Maternal Health Committee 150.00 

Public Relations Committee 700.00 

Ethics Committee 100.00 

Membership Committee 25.00 

Joint Com. on H. E 500.00 

Adv. to Woman’s Auxiliary 50.00 

Sundry Other Committees 325.00 

Committee Reserve 500.00 


Total Committee Expenses $ 9,725.00 


Grand Total $ 43,800.00 

BUDGET FOR “THE TOURNAL”— 1939 
INCOME: 

Subscriptions from members $6,300.00 

Other subscriptions 100.00 

Advertising 9,500.00 

Reprint Sales 1.500.00 

Journal Cuts 125.00 


$17,525.00 

EXPENSES: 

Editor’s salary $3,000.00 

Printing and mailing 9,500.00 

Cost of reprints 1,400.00 

Discounts and commissions on 

advertising 1,150.00 

Postage 250.00 

General office expense 1,800.00 

Reserve 425.00 


$ 17 , 525.00 

Motion of Drs. Andrews-Haughey that the report 
as a whole be adopted. Carried unanimous!}". 


REFERENCE REPORT OF FINANCE 
COMMITTEE 

15. Report of Finance Committee was read by 
Dr. Carstens. The Ernst & Ernst statement was 
studied. Treasurer Wm. A. Hyland commented 
briefly on his report and the condition of the bonds. 
Motion of Drs. Cummings-Mclntyre that the Bond 
Committee be empowered to dispose of certain 
bonds, at its discretion. Carried unanimously. 

The budget for 1939 was presented and discussed 
item by item. Motion of Drs. Holmes-Sladek that 
the salary of Executive Secretary Burns be set at 
$7,000 per annum in the budget outlined. Carried 
unanimously. Motion of Drs. Sherman-Hart that 
the salaries of the employees be set as recommended 
by the Finance Committee: Leet, $2100; Shepline, 
$1500; Tracy, $1320; Rehm, $900. Carried unani- 

March, 1939 


mously. Motion of Drs. Mclntyre-Cummings that 
the recommendations of the Finance Committee on 
administrative and General appropriations be ap- 
proved. Carried unanimously. Motion of Drs. 
Holmes-Andrews that the recommendations of the 
Finance Committee on Society Expense be approved. 
Carried unanimously. Motion of Drs. DeGurse-Sla- 
dek that the recommendations of the Finance Com- 
mittee on Committee Expense be approved. Carried 
unanimously. Motion of Drs. Cummings-Sherman 
that the budget as recommended by the Finance 
Committee be adopted as a whole. Carried unani- 
mously. 

Journal Budget. Motion of Drs. Holmes-Sladek 
that the recommendations of the Finance Committee 
re The Journal be adopted as a whole. Carried 
unanimously. 


THIRD SESSION 

16. The Council reconvened at 8:15 p.m. — Min- 
utes of the Morning and Afternoon Sessions of The 
Council were read and approved. 

17. Voluntary Group Hospitalization and Group 
Medical Care. Dr. H. A. Miller, Chairman of the 
Legislative Committee reported on legislative ac- 
tivity relative to group hospitalization and group 
medical care. The proposed enabling act for group 
medical care was read in its entirety. The proposed 
enabling act for group hospitalization submitted by 
the Michigan Hospital Association was also read in 
its entirety. Dr. Miller read the report of the meet- 
ing of representatives of the MSMS with represen- 
tatives of the Michigan Hosp. Ass’n in Flint on 
Sunday, January 22. Further discussion of group 
hospitalization and group medical care was deferred 
until January 29, when The Council is to meet with 
representatives of the Michigan Hospital Ass’n. 

18. The American Academy of Pediatrics’ pro- 
posal re an immunization program was presented by 
Secretary Foster. Motion of Dr. Holmes, seconded 
by several, that the program as presented be ap- 
proved. Carried unanimously. 

19. Report of the Chairman of the Contact Com- 
mittee to Governmental Agencies, Dr. Henry Cook, 
was read by Secretary Foster. Motion of Drs. An- 
drews-McIntyre that the report be accepted. Car- 
ried unanimously. The Council recessed at 10 :50 
p. m. 


FOURTH SESSION 

January 29, 1939 

20. Roll Call. — The meeting was called to order 
at 10 :05 a. m. 

The Minutes of the session of January 28 were 
read and approved. 

21. Bills Payable. — The statement from attorneys 
of the Medico-Legal Committee was presented, and 
motion was made by Drs. Holmes-Carstens that the 
retainer fee be paid. Carried unanimously. The bill 
of Douglas, Barbour, Desenberg and Purdy for le- 
gal services was presented and discussed. Motion 
of Drs. Andrews-Carstens that the bill be paid. 
Carried unanimously. 

Bills payable for the month were presented and 
motion was made by Drs. Carstens-Mclntyre that 
they be paid. Carried unanimousE- 

22. Special Committee on Medico-Legal Activity. 
— After discussion of the activities of the Medico- 
Legal Committee, the Chair appointed Dr. V. M. 
Moore to the Special Committee on Medico-Legal 
Activity to fill the vacancy left by the resignation 
of Dr. Greene. The Committee is now composed 
of Drs. Holmes, chairman ; Andrews and Moore. 

23. Group Hospitalisation. — Mr. Ralph M. Hues- 
ton. President of the Michigan Hospital Associa- 
tion, Mr. Wm. J. Griffin, Mr. Robt Greve, and Mr. 
John Mannix were intioduced to the members of 


245 


MID-WINTER MEETING OF THE COUNCIL 


the Council. The protocol developed at the meeting 
in Flint on January 22, which defines professional 
medical service, was read. Mr. Hueston explained 
the intentions of the Hospital Association in its 
group hospitalization plans with relation to the tech- 
nical service and professional service. Nurse anaes- 
thetists were discussed thoroughly. The Michigan 
Society for Group Hospitalization has agreed not 
to include anything in its contract with the sub- 
scriber re x-ray service. Motion of Drs. Moore- 
several that the following sentence be added to the 
protocol, which has the approval of the representa- 
tives of the Michigan Hospital Association present : 
“Notwithstanding the above definition, it is agreed 
that the hospital program will not include any x-ray 
service.” Carried unanimously. Motion of Drs. 
Andrews-Sladek that the protocol with the above 
addition be approved. Carried, Dr. McIntyre dis- 
senting. 

The MSMS proposed enabling act for group 
medical care was discussed with the representatives 
of the Michigan Hospital Association. The MHA 
proposed enabling act for group hospitalization was 
presented. 

Motion of Drs. Moore-Mclntyre that The Coun- 
cil of the Michigan State Medical Society approve 
the Group Hospital plans as presented by the Mich- 
igan Society for Group Hospitalization, (the plan 
of the Michigan Hospital Association) and ex- 
presses itself to be in accord with the plan and to 
lend its support. Carried unanimously. 

Motion of Drs. Holmes-Mclntyre that the repre- 
sentatives of the Michigan Hospital Association be 
requested to present the proposed enabling act for 
group medical care drafted by the MSMS, to the 
Michigan Hospital Association for its endorsement 
and support. Carried unanimously. 

Mr. Hueston thanked The Council on behalf of 
the Michigan Hospital Association for the cour- 
tesy extended to him and other representatives of 
the MHA. Mr. Hueston stated that the MHA will 
work for the passage of both enabling acts. 

Mr. Mannix, newly appointed Executive Director 
of the Michigan Society for Group Hospitalization, 
outlined the method of operation and reviewed the 
experience of group hospitalization in the U. S. 

ELECTIONS 

24. (a) Election of Secretary. — Motion of Drs. 
Andrews-several that Dr. L. Fernald Foster of Bay 
City be re-elected Secretary. Carried unanimously. 

(b) Election of Treasurer. — Motion of Drs. 
Moore-several that Dr. Wm. A. Hyland of Grand 
Rapids be re-elected Treasurer. Carried unani- 
mously. 

(c) Election of Editor. — Motion of Drs. Holmes- 
Mclntyre that Dr. James H. Dempster of Detroit 
be re-elected Editor of The Journal. Carried un- 
animously. 

(d) Appointment of Executive Secretary. — Mo- 
tion of Drs. Cummings-Sladek that Mr. Wm. J. 
Burns be re-appointed Executive Secretary. Car- 
ried unanimously. 

(e) Resignation of Dr. Greene. — From Chair- 
manship of the County Societies Committee and 
membership on the Executive Committee was pre- 
sented. Motion of Drs. Brunk-Mclntyre that Dr. 
Greene’s resignation as stated above be accepted 
with great regret that Dr. Greene does not feel able 
to carry on with these duties. Carried unanimously. 

Election of County Societies Committee Chair- 
man. — Dr. McIntyre-several moved that Dr. Wil- 
frid Haughey of Battle Creek be nominated. Mo- 
tion of Drs. Carstens-Cummings that the nomina- 
tions be closed and a unanimous ballot be cast for 
Dr. Haughey. It was so cast by the Secretary. 


(f) Medico-Legal Defense Committee. — Motion 
of Drs. Moore-Cummings that Dr. Wm. R. Torger- 
son of Grand Rapids and Dr. S. W. Donaldson of 
Ann Arbor be elected members of the Medico-Legal 
Committee. Carried unanimously. Motion of Drs. 
Holmes-Barstow that Dr. F. T. Andrews of Kala- 
mazoo be the third member of the Committee. Car- 
ried unanimously. 

Motion of Drs. Barstow-DeGurse that Dr. Angus 
McLean and Dr. Wm. J. Stapleton, Jr. be re-elected 
to the Committee. Carried. 

Motion of Drs. Moore-Cummings that Dr. Tor- 
gerson be elected Chairman. Carried unanimously. 

Motion of Drs. Holmes-Carstens that the salary 
of the Chairman be set at zero. Carried unani- 
mously. 

25. Tour of U. P. County Societies. — Dr. Huron 
spoke of the appreciation of the officers of the Up- 
per Peninsula Societies for the visit of MSMS 
officers each year. Motion of Drs. Huron-Sladek 
that the annual tour of the Upper Peninsula Medi- 
cal Societies be authorized for 1939. Carried unani- 
mously. 

Recess for dinner : 12 :50 p. m. 


FIFTH SESSION 

The Council reconvened at 2:40 p. m. 

26. Release to newspapers re agreement of Michi- 
gan State Medical Society and Michigan Hospital 
Association on the subject of group hospitalization 
and group medical care was read by President Luce. 
Motion of Drs. Andrews-Mclntyre that the story be 
approved with the addition of the following sen- 
tence in the second paragraph : “Plans for group 
medical service .sponsored by the Michigan State 
Medical Society will soon be instituted by that or- 
ganization,” and released to all newspapers of the 
State. Carried unanimously. 

27. Cancer Subcommittee. — The list of nomina- 
tions by the Cancer Committee of men from all 
areas of the state was presented. Motion of Drs. 
Carstens-Mclntyre that the list be approved and 
that list be designated as Speakers Bureau of Can- 
cer Committee, and that the Secretary notify the 
Committee that further names be considered as ad- 
ditions to it on advice of county medical societies. 
Carried unanimously. 

28. Interne Training. — Dr. McIntyre remarked 
briefly re interne training. Letter of Dean Allen of 
Wayne University Medical College was read. 

29. Income Tax Status. — Motion of Drs. Mcln- 
tyre-Andrews that another letter be directed to the 
Department of Internal Revenue and that additional 
legal advice be soqght in the matter. Carried unan- 
imously. 

30. Adjournment. — The Chair thanked all for 
their attendance, good attention and advice, and ad- 
journed the meeting at 4:30 p. m. 


The Poor Fish 

Herr Hitler and Signor Mussolini sat fishing to- 
gether on one side of the lake, and Mr. Chamberlain 
on the other. But while the British Prime Minister 
caught fish after fish, the two dictators could not 
even raise a bite. 

“How do you do it, Neville?” they shouted across 
the water. “There don’t seem to be any fish on our 
side.” 

“The fish are there all right,” replied Mr. Cham- 
berlain, “but they daren’t open their mouths.” — Lon- 
don News-Letter. 


246 


Jour. M.S.M.S. 


REPORT OF AUDITORS FOR 1938 


REPORT OF AUDITORS FOR 1938 

W E have made an examination of the balance 
sheet of Michigan State Medical Society 
as at December 24, 1938, and of the state- 
ments of income and expense for the year ended at 
that date. In connection therewith, we examined or 
tested accounting records of the Society and other 
supporting evidence and obtained information and 
explanations from the Executive Secretary and 
employees. We also made a general review of the 
accounting methods and of the operating and income 
accounts for the year and made certain certain test 
checks of the records of cash transactions and data 
supporting the operating and income accounts as 
hereinafter outlined, but we did not make a detailed 
audit of the transactions. 

The Society was organized under the laws of 
the State of Michigan on September 17, 1910, as a 
corporation not for pecuniary profit. It is affiliated 
with the American Medical Association and charters 
county medical societies within the State of Michi- 
gan. The purposes of the Society are the promotion 
of the science and art of medicine, the protection of 
public health and the betterment of the medical pro- 
fession. In the furtherance of these purposes, the 
Society publishes The Journal of the Michigan 
State Medical Society. 

Balance Sheet 

A summary of the balance sheets at December 
24, 1938, and December 24, 1937, follows : 


ued from information furnished by brokers as to 
the current bid and sale prices. The only change 
during the year in the securities owned by the So- 
ciety was occasioned by the receipt of a first and 
final dividend on bonds of the National Electric 
Power Company, in the principal amount of 
$5,000.00, held in the General Fund of the Society. 
The net loss on these securities in the amount of 
$4,462.21 was practically offset by a reduction in 
the reserve to reduce securities to aggregate quoted 
market prices at December 24, 1938. The reserve 
applicable to securities of the Medico-Legal_ Defense 
Fund has been increased in the amount of $648.00. 
The net effect of the disposal of securities and ad- 
justment of the reserve for securities is shown in 
the following summary: 


Change in reserve for securi- 


NET LOSS ON SECU- 



General 

Medico- 

Legal 

Defense 

Total 

Fund 

Fund 

.$4,462.21 

$4,462.21 


. 4,418.50 

5,066.50 

648.00 

$ 43.71 

$ 604.29 

$648.00 


None of the bonds owned by the Society are in 
default. Matured coupons not cashed at December 
24, 1938, have been included at face amount, but no 
other accrued interest receivable has been included 
in the balance sheet. 

Deferred Charges as shown in the balance sheet 


ASSETS 

DEC. 24, 1938 

DEC. 24, 1937 

INCREASE 

DECREASE 

Cash 


$ 1,473.45 

$ 8,177.33 

Notes and accounts receivable 

5,274.35 

920.48 

4,353.87 

Inventory 

834.00 

834.00 

Securities — at cost, less reserve 

28,779.00 

28,978.00 

199.00 

Deferred charges 


76.46 

40.96 


$43,821.55 

$32,282.39 

$11,539.16 

LIABILITIES 

Note payable 

$ 3,500.00 

$ 3,500.00 

Accounts payable 


2,855.53 

1,571.49 

Liability for funds administered 

39.37 

39.37 


Unearned income 


2,074.50 

4,596.50 

Reserve for Medico- Legal Defense Fund 

9,225.30 

12,048.60 

2,823.30 

Net worth 


11,764.39 

14,837.45 


$43,821.55 

$32,282.39 

$11,539.16 


Notes receivable for dues represent the uncollected portions of notes taken in settlement of 1931, 
1932 and 1933 dues. No payments were received on these notes during the year ended December 24, 1938. 

Accounts receivable for advertising, reprints and cuts were analyzed as to date of charge and are 
classified in comparison with the balances at December 24, 1937, as follows: 


DECEMBER 24, 1938 


DATE OF CHARGE Amount Per Cent 

October, November and December $ 946.58 73.26% 

July, August and September 198.50 15.37% 

January to June,, inclusive 22.47 1.74% 

Prior to January 1 124.45 9.63% 


DECEMBER 24, 1937 
Amount Per Cent 


$ 981.51 70.59% 

100.45 7.23% 

10.25 .74% 

298.08 21.44% 


TOTAL $1,292.00 100.00% 


$1,390.29 100.00% 


The balances due from county societies represent 
dues collected for the Society by two county socie- 
ties and impounded in depositary banks. As funds 
are released by the banks, the Society’s share is to 
be forwarded by the county societies. No payments 
were received during the year on these two ac- 
counts. Accounts receivable from exhibitors for 
space at the 1939 annual meeting include only ac- 
counts with exhibitors who have made deposits on 
the spaces reserved for them. In prior years, reser- 
vations have not been taken prior to the close of 
the year. The income from the sale of this space 
has been deferred to the 1939 period. The collecti- 
bility of the notes and accounts receivable was dis- 
cussed with the Executive Secretary and, in our 
opinion, the reserve in the amount of $425.00 is suf- 
ficient to provide for collection losses anticipated at 
the date of this report. 

A schedule of securities owned is included in a 
later section of this report and sets forth the prin- 
cipal amount, cost and quoted market prices at De- 
cember 24, 1938. Unlisted securities have been val- 


represent costs incurred prior to December 24, 1938, 
in connection with advertising for the 1939 annual 
meeting. In our opinion, such items are properly 
chargeable to future operations. 

As far as we could ascertain, provision has been 
made for all liabilities at December 24, 1938. No 
provision has been made, however, for any liability 
that the Society might have in connection with pay 
roll taxes for the years 1936, 1937 and 1938, as there 
is a question as to whether or not the Society is 
liable for such taxes. No pay roll taxes have been 
paid by the Society nor have any assessments been 
made by taxing authorities. 

Income from the rental of exhibitors’ space at the 
1939 annual meeting has been deferred, as mentioned 
heretofore. Collections of 1939 dues and overpay- 
ments of dues for prior years have also been shown 
as unearned income, and, in our opinion, represent 
income applicable to the ensuing year, except such 
portion as will be credited to the Medico-Legal De- 
fense Fund, when it is determined what portion, if 
any, of 1939 dues will be allocated to that fund. 


March, 1939 


247 


REPORT OF AUDITORS FOR 1938 


A separate schedule included herein shows in 
summary the changes in the Medico-Legal Defense 
Fund Reserve. In prior years, a certain portion of 
each member’s dues and the interest and dividends 
on securities allocated to that fund have been cred- 
ited to the reserve. During the year ended Decem- 
ber 24, 1938, this reserve has been credited only with 
a portion of 1937 dues collected in 1938 and interest 
and dividends on investments, although it was noted 
that the budget for the year 1938, approved at the 
Council meeting on January 13, 1938, provided an 
appropriation of $3,500.00 to the Medico-Legal De- 
fense Fund. Due to the fact that receipts credited 
to this fund during the year amounted to only 
$528.65, this reserve was materially reduced. The 
additional reserve to reduce securities in this fund 
to their aggregate quoted market prices at December 
24, 1938, in the amount of $648.00 has also been 
charged to the Medico-Legal Defense Fund Re- 
serve. 

Surety bonds on officials and an employee of the 
Society at December 24, 1938, were as follows : 
Medical Secretary, $15,000.00; Treasurer, $35,000.00; 
Executive Secretary, $5,000.00 ; Bookkeeper, $5,000.00. 

Income and Expense Statement 

A statement of income and expense for the fiscal 
year ended December 24, 1938, is included herein, 
prepared in comparison with the statement for the 
preceding year. A comparative statement of ex- 
penses for the two years is also included. 

The increase in income from membership fees 
arises from the increase in the amount of the an- 
nual dues to $12.00 and to the fact that no portion 
of current fees was allocated to the Medico-Legal 
Defense Fund as mentioned previously. There was 
also an increase in the membership of the Society 
during the year. 

As in prior years, $1.50 of each member’s annual 
membership fee has been allocated to subscription 
income of The Journal of the Michigan State 
Medical Society. Net income of the Journal was 


slightly more than during the preceding year. We 
call attention to the fact that income of the Journal 
is not charged with any part of the expenses of the 
executive office. 

Scope of Examination 

The scope and nature of our examination and the 
extent of our tests of the detail transactions are out- 
lined in the following comments : 

The demand deposit and savings deposit were 
confirmed by correspondence ' with the depositary 
bank and by reconcilement of the balances reported 
to the amounts shown herein. The office cash fund 
was counted on the morning of December 28, 1938, 
and our count was reconciled to the amount shown 
herein. Recorded cash receipts for six months of 
the year under review were traced to deposits 
shown by the bank statements on file. The recorded 
cash disbursements for three months of the year 
were compared with canceled bank checks, invoices 
and other memoranda. To the extent of the tests 
made, no irregularities were disclosed. 

Notes receivable were inspected by us. Accounts 
receivable were in agreement with trial balances of 
the individual accounts. We did not correspond with 
any of the debtors to confirm the accuracy of the 
book records. We examined contracts and other 
data to confirm accounts receivable from exhibitors 
for space at the 1939 annual meeting. The amount 
shown as due from the Grand Rapids Trust Com- 
pany was confirmed by correspondence with that 
company. 

Securities were inspected on December 27, 1938, 
and market quotations were obtained to ascertain 
their market prices at December 24, 1938. 

We did not correspond with the recorded credi- 
tors of the Society to confirm the liabilities at De- 
cember 24, 1938; however, we examined unpaid in- 
voices, expense reports, etc., received subsequent to 
that date to ascertain that all liabilities have been 
provided for. Transactions entering into the ac- 


BALANCE SHEET 
December 24, 1938 
Assets 


Cash 

Demand deposit $ 4,611.25 

Office cash fund 6.20 

Savings deposit 5,033.33 


Notes and Accounts Receivable 

Notes receivable for dues-. — past due $ 80.00 

Accounts receivable : 

For advertising, reprints and cuts $1,292.00 

From county societies for dues 75.19 

From exhibitors, for space at 1939 annual meeting. . 4,158.18 5,525.37 

$5,605.37 

Less Reserve 425.00 


$ 9,650.78 


Grand Rapids Trust Company 

Securities 

Stocks and bonds — at cost 

Less reserve to reduce to aggregate quoted market prices.. 
Unclipped matured coupons on bonds 

Deferred Charges 

Expense in connection with 1939 annual meeting 


$ 5,180.37 
93.98 

5,274.35 

$34,611.25 

6,007.25 $28,604.00 

175.00 

- — — 28,779.00 

117.42 


Liabilities 

Accounts Payable 

For current expenses, etc 

Liability for Fund Administered 

Couzens Foundation 

Unearned Income 

Sale of exhibitors’ space at 1939 annual meeting 

Dues for the year 1939 

Reserve 

For Medico-Legal Defense Fund 

Net Worth 

Balance at December 25, 1937 

Net increase for the year ended December 24, 1938... 


$43,821.55 


$ 1,284.04 
39.37 

$ 5,242.50 
1,428.50 

6,671.00 

9,225.30 

$11,764.39 

14,837.45 

26,601.84 


248 


$43,821.55 

Jour. M.S.M.S. 


REPORT OF AUDITORS FOR 1938 


INCOME AND EXPENSE STATEMENT 
FISCAL YEAR ENDED DECEMBER 24, 1938 


Income 

Membership fees $49,192.00 

Less: Allocated to Journal income for sub- 
scriptions 6,151.12 

Allocated to Medico-Legal Defense Fund 4.25 


$ 6,155.37 


Net Income from Membership Fees $43,036.63 

Income from Journal — as shown by schedule 1,942.98 

Interest received 708.33 

Miscellaneous income 156.98 


Total Income $45,844.92 

Expenses — as shown by schedule 

Administrative and general office $16,949.26 

Society activities 7,655.40 

Committee expenses 6,135.57 


$30,740.23 


$15,104.69 

Other Deductions 

Loss on sale of securities $ 4,462.21 

Adjustment of inventory of ‘‘Medical History of 

Michigan” 834.00 

Interest paid 22.45 

Bad accounts charged off or provided for .08 

Miscellaneous 15.00 


EXPENSES 

FISCAL YEAR ENDED DECEMBER 24, 1938 


Administrative and General 

Secretary’s salary $ 2,400.00 

Executive secretary’s salary 6,000.00 

Other office salaries 4,000.05 

Office rent 720.00 

Printing, stationery and supplies 989.91 

Postage 738.02 

Auditing 250.00 

Insurance and fidelity bonds 190.77 

Telephone and telegraph 460.55 

Legal expense 35.00 

New equipment 994.78 

Unclassified 170.18 


$16,949.26 

Society Activities 

Council expenses $ 3,012.50 

Education expenses 

Delegates to American Medical Association... 1,675.56 

Secretaries’ conference 740.61 

Secretary’s letters 523.28 

Traveling expense 2,218.63 

Legal expense 

Reporting annual meeting 130.39 

Organizational expense 

Publications 18.90 

Honorarium 

American Medical Association survey 29.38 

Sundry society expense 820.59 


$ 5,333.74 


Net Income $ 9,770.95 

Add adjustment of reserve to reduce securities of 

the General Fund to quoted market prices 5,066.50 


Increase in Net Worth $14,837.45 


INCOME FROM “THE JOURNAL OF THE MICHI- 
GAN STATE MEDICAL SOCIETY” 

FISCAL YEAR ENDED DECEMBER 24, 1938 


Income 

Subscriptions from members $ 6,151.12 

Other subscriptions 112.00 

Advertising 10,269.20 

Reprint sales 1,857.98 

Journal cuts 166.96 


Expenses 

Editor’s salary $ 3,000.00 

Editor’s expense . 600.00 

Printing and mailing 10,144.90 

Cost of reprints 1,423.21 

Discount and commissions on advertising 1,196.17 

Postage 250.00 


$16,614.28 


Net Income $ 1,942.98 


$ 9,169.84 

Less revenue from annual meeting in excess of 


cost thereof 1,514.44 


$ 7,655.40 

Committee Expenses 

Legislation committee $ 775.29 

Committee on distribution of medical care 676.12 

Contribution to Joint Committee on Public 

Health Education 875.00 

Cancer committee 802.95 

Preventive medicine committee 119.51 

Postgraduate conferences 1,328.80 

Public relations committee 509.10 

Ethics committee 42.72 

Economics committee .• 

Maternal welfare committee 150.10 

Iodized salt committee 286.25 

Advisory committee on women’s auxiliary' 110.74 

Sundry other committees 458.99 


$ 6,135.57 


Total $30,740.23 


MEDICO-LEGAL DEFENSE FUND RESERVE 
FISCAL YEAR ENDED DECEMBER 24, 1938 
Balance at December 25, 1937 


Disbursements 

Douglas, Barbour, Duesenberg and Purdy — legal services $1,682.06 

Wm. Stapleton, Jr. — salary 999.96 

Miscellaneous 21.93 


Receipts 

Interest received on securities $ 524.40 

Apportionment of 1937 membership fees collected in 1938 4.25 


$12,048.60 


$2,703.95 


528.65 

2,175.30 


$ 9,873.30 

Increase in reserve to reduce securities to aggregate quoted market prices. . 648.00 


Balance at December 24, 1938 

counts of the Medico-Legal Defense Fund for the 
year were reviewed by us. 

In addition to our examination of the items in- 
cluded in the balance sheet as outlined above, we 
made tests of transactions entering into the income 
and expense accounts. Unused membership certifi- 
cates were examined to confirm the income from 
dues. Interest received was checked by inspection 
of unclipped coupons on bonds. Tests of advertis- 
ing income were made by comparison of billings 
for advertising with space used in three issues of 
the Journal. We also reviewed the items charged 
to the major expense accounts for the year. 

March. 1939 


$ 9,225.30 

Opinion 

In our opinion, based upon our examination, the 
accompanying balance sheet and related statements 
of income and expense fairly present the position 
of the Society at December 24, 1938, and the results 
of its operations for the year ended at that date. 
Further, it is our opinion that the statements have 
been prepared in accordance with accepted princi- 
ples of accounting and on a basis consistent with 
the preceding year. 

Ernst & Ernst, 

Certified Public Accountants 


249 


4 WOMAN’S AUXILIARY 4 

President — Mrs. P. R. Urmston, 1862 McKinley Avenue, Bay City, Michigan 
Sec.-Treas. — Mrs. R. E. Scrafford, 2210 McKinley Ave., Bay City. Michigan 
Press — Mrs. J. W. Page, 119 N. Wisner Street, Jackson, Michigan 


PUBLIC RELATIONS 

This year the Public Relations Committee of the 
Woman’s Auxiliary faces two major questions — 
group hospitalization and socialized medicine, both 
of which have occupied the attention of the State 
Medical Society for several months. 



(Photo by Coulter Studio, Grand Rapids, Mich.) 


Anna S. Collisi 

Although the State Society as yet has not re- 
quested the assistance of the auxiliary it would be 
well to be thoroughly cognizant of the action of 
the House of Delegates, and to become properly 
informed on the subject of group hospitalization. 
When and if plans are adopted, auxiliary members 
would be prepared to discuss this most vital ques- 
tion in women’s clubs and organizations whenever 
appropriate occasions arise. 

Socialized medicine has been publicized so long 
that every auxiliary member has some knowledge 
of it. The question is so vital to the medical pro- 
fession that auxiliary members should thoroughly 
understand it and be prepared to discuss it in 
every way, particularly its effect upon the confi- 
dential relationship of physician and patient. 

Both group hospitalization and socialized medi- 
cine will require enabling legislation before they can 
be made effective. 

Obviously, the important factors by which can 
be disseminated are medical speakers at lay meet- 
ings and press articles by lay writers. The facts 
must come from authentic medical sources — the 
Public Relations Committees of the State Society 
and the Woman’s Auxiliary. 

May I urge each County Public Relations Com- 
mittee and individual auxiliary member to begin 
at once a most thorough study of these two ques- 
tions ; that they contact as many lay groups as 

250 


possible ; and that they become civic-conscious to 
the extent that it will react favorably in gaining 
public support and confidence. 

Respectfully submitted, 

Anna S. Collisi, Chairman, 
Public Relations Committee. 


Jackson County 

Tuesday evening, January 17, the Women’s 
Auxiliary held a dinner meeting at the Hotel 
Hayes. 

The group was greatly honored by the presence 
of Dr. Morris Fishbein, who talked for a few min- 
utes before going into the Medical Society’s meeting, 
where he spent the remainder of the evening. Dr. 
Fishbein spoke briefly of the legislative problems 
confronting the medical field. He said compulsory 
health insurance holds two major threats. First, it 
would deteriorate the general quality of medical 
service. Second, it would represent a definite step 
in the direction of totalitarianism, a system in which 
the worker might conceivably be paying a substantial 
portion of his wages to the government for service 
which, under our Democratic system, he should be 
paying for directly himself, but which the govern- 
ment would be providing for him. 

Dr. Fishbein spoke favorably of the voluntary non- 
profit cash indemnifying program of group medical 
and hospital insurance which, earlier this month, 
was approved by the house of delegates of the Mich- 
igan State Medical Society. 

Following Dr. Fishbein’s talk, Mr. Bullen intro- 
duced Rev. Carl Winters, who gave a review of the 
current New York plays. He commented briefly on 
“Pins and Needles,” “Sing Out the News,” “Abe 
Lincoln In Illinois,” “Hell’s Apoppin’,” and spoke 
more at length on “Knickerbocker Holiday.” 

Co-chairmen of arrangements for the evening 
were Mrs. Hanna and Mrs. McGarvey. 

Anna Hyde Shaeffer, 
Press Chairman. 


Kent County 

January proved to be an interesting month for 
auxiliary members. The Persian Coffee, given under 
the auspices of the Hygeia and Philanthropic com- 
mittees, was not only a financial success but very 
enjoyable. Mrs. Carl F. Snapp, our hostess, who j 
opened her home for the affair, was assisted by our 
President, Mrs. William J. Butler. Co-chairmen 
were Mrs. Wallace H. Steffensen and Mrs. Joseph 
C. Tiffany, and very special compliments, indeed, go 
to Mrs. David B. Davis, whose delightful piano se- 
lections added so much charm and atmosphere. 
However, not the least of the credit is enthusiasti- 
cally given to Mrs. Robert M. Eaton, whose tales of 
the charms of Persia inspired the whole affair and 
who, with her two children, exhibited authentic Per- 
sian costumes and curios. 

At our regular meeting we enjoyed an enlightening 
talk given by Mr. Charles Orin Ransford, President 
of Herpolsheimer’s department store, who chose as 
his topic “Economic Measles.” Mr. Ransford is 
quite an authority on the subject, having conducted 
a survey of retail business in the United States, and 
(Continued on page 252) 

Jour. M.S.M.S. 



ADVERTISING SECTION— M. S. M. S. 



t l/VDI 9lTl 1 1 vrL unm o cvuqentn 

for the patient with early syphilis 

for the patient who is sensitive to arsenic 


lODOBISMITOL 

„ «U«< 


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ascle. On- =®p’ 

, nf . -l.nuM t~ m 

r«— •• "t* ^ 

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fi gliKU- rnaxiinne 

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TOOScrative 

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being P'-mi. 

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A RECENTLY PUBLISHED 
clinical study 1 of combination bismuth therapy 
includes the comment that: "One of the prob- 
lems of bismuth therapy for syphilis is to achieve 
a rapid rise of the metal in the blood stream 
to a therapeutic level and to keep it there with- 
out too great hardship on the patient. . . . This 
we believe we have achieved by the combined use 
of iodobismitol or sobisminol and weekly injec- 
tions of bismuth subsalicylate. . . . Such a form of 
bismuth therapy would be particularly useful in 
the acute stage of syphilis when the patient is sen- 
sitive to arsenic and it is necessary to rely on other 
antisyphilitic measures. Moreover, for the patient 


with early syphilis, who is just starting therapy, 
this schema might be employed in the first course 
of bismuth therapy when the clinician is desirous 
of dealing a heavy blow to the spirochetes from 
another angle than that of arsenic.” 

Iodobismitol with Saligenin is a propylene gly- 
col solution containing 6% sodium iodobismuth- 
ite, 12% sodium iodide, and 4% saligenin (a local 
anesthetic) . 

It is rapidly absorbed and slowly excreted 
and is useful in both early and late syphilis. 
It presents bismuth largely in anionic (electro- 
negative) form. 

1 JI. A. M. aL 111 :2175 (Dec. 10), 1938. 


SQUIBB ARSENICALS 

Neoarsphenamine Squibb, Arsphenamine Squibb, and Sulpharsphenamine Squibb 
are prepared to produce maximum therapeutic benefit. They are subjected to exact- 
ing controls to assure a high margin of safety, uniform strength, ready solubility, 
and high spirocheticidal activity. 

For literature urrite to Professional Service Department, 745 Fifth Avenue, New York 

ER: Squibb & Sons. New York 

MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858 



March, 1939 


251 


MICHIGAN’S DEPARTMENT OF HEALTH 


claimed that the method of attacking our problems 
has been wrong, because we have taken the short 
range viewpoint and treated each new problem as a 
crisis instead of assigning it to its proper place in 
the general scheme of things. 

Plans are already being made for spring, including 
arrangements for our annual open tea in April, 
which will feature an exhibit of members’ hobbies. 

Jane R. Frantz, 
Press Chairman. 


Kalamazoo County 

On January 17, thirty-five members of the Wom- 
an’s Auxiliary to the Academy of Medicine met at 
the home of Mrs. Ralph Fast for a cooperative din- 
ner and a business meeting. 

The President announced that the Auxiliary had 
been asked to send a representative to the Child 
Welfare Board. 

Mrs. F. T. Andrews explained the indictment of 
the physicians in Washington, also the threat of the 
government to assess the American Medical Asso- 
ciation. 

Five ladies were welcomed as new members to 
the Auxiliary. 

Following the business meeting, bridge and sew- 
ing were enjoyed. 

(Mrs. Hugo) Barbara K. Aach, 
Publicity Chairman. 


Saginaw County 

Forty-five members of the Saginaw County Medi- 
cal Auxiliary met at the home of Mrs. F. J. Cady 
Tuesday evening, January 17. A business and social 
hour were enjoyed. House prizes were received by 
Mrs. Louis D. Gomon and Mrs. Donald V. Sargent. 
Refreshments were served by the hostess with the 
social committee, consisting of Mrs. Henry J. Meyer, 
chairman; Mrs. Wm. P. Martzawka and Mrs. J. A. 
Maurer, assisting. 

Mrs. Milton G. Butler, 
Publicity Chairman. 


A Perverted Era 

Many people are inclined to lay too much stress 
on the achievements of our time. We admit the 
progress in science and industry, but we deplore the 
decline in ethics and social relationship. The Ten 
Commandments are not observed as they should be. 

Of course, everybody knows now that two main 
factors are at work. One is overpopulation, and 
the other the lack of adjustment of human relations 
to mechanics. The perversion which is shown by 
utilizing technical progress for mass destruction 
is perhaps the most discouraging symptom of mod- 
ern times. It is true that every nation has a large 
number of intelligent people. They are, however, 
more or less powerless at present. The psychologist 
James saw that the whole world is actuated by “in- 
terest and emotion,” as Schiller saw by “hunger and 
by love.” People must eat. If there are too many 
people, they want their neighbors’ food, and there 
is war. Why do people not use common sense? 

A great change must come in the education of 
the masses, .so that a more secure foundation is laid 
for a well regulated population. There are great 
modern problems to be solved. War will not help 
the situation. An enlightened humanity, in order to 
get order in the world, must start again on the 
right track which begins with the Ten Command- 
ments. — Dr. Emil Amberg, in The Rainboze. 


MICHIGAN’S DEPARTMENT 
OF HEALTH 

DON W. GUDAKUNST, M.D., Commissioner 

LANSING, MICHIGAN 

COMMUNICABLE DISEASE REGULA- 
TIONS REVISED 

Rules and regulations of the Michigan Department 
of Health for the control of communicable diseases 
were considered by the State Council of Health 
meeting in advisory session with the state health 
commissioner at Lansing, January 11. The Coun- 
cil approved the following changes and additions j 
to the regulations which become effective immedi- s 
ately : 

1. All bites of humans by any dog are reportable ] 
to the health officer and to the Michigan Depart- 
ment of Health in the same manner as communicable , 
disease and suspected communicable disease cases 1 
are reported. 

2. All cases and types of pneumonia are desig- 
nated to be reportable diseases. Pneumonia is to be ] 
reported as either bronchial or lobar pneumonia, 
and the type of organism causing the disease shall 
be reported whenever the sputum examination has 1 
revealed the type. 

3. Blastomycosis is declared to be a reportable ] 
disease. 

4. All diarrheas accompanied b a bloody dis- 
charge from the bowel shall be reportable and shall 
be reported as dysentery. All dysenteries shall be 
reported by type of causative organisms, when such 
has been determined. 

5. Diarrheas of the newborn (infants under one 
month of age) occurring in babies in hospitals li- 
censed or operating as maternity hospitals are de- 
clared to be reportable conditions. The circum- 
stances surrounding the development of such dis- 
ease must be investigated by the local or State 
Department of Health. 

6. Paratyphoid fever shall be reported by type 
and sub-classification. 

7. Influenza is declared to be a reportable disease 
at all times and not solely during epidemics. 

8. Streptococcus sore throat is declared to be a 
reportable disease at all times and not solely dur- 
ing epidemics. 

9. The disease favus is declared to be no longer 
a reportable disease. 

10. The disease mumps is declared to be no longer 
a reportable disease. 

11. Patients with rubella (German measles) need 
not be isolated nor contacts quarantined. However, 
children with the disease must be excluded from 
school and other public gatherings during the course 
of the disease. 

12. Adult contacts, familial and extra-familial, to 
scarlet fever need not be quarantined unless the 
occupation of such contacts has to do with caring 
for children and the handling of food in any form. 

13. The quarantine period for contacts to cases 
of poliomyelitis shall be reduced from fourteen days 
to seven days. 

14. For the purpose of these regulations the term 
“isolation” shall be used to refer to the restrictions 
placed upon persons ill with, or suspected of having, 
a communicable disease. The term “quarantine" 
sh